The link between Disassociation and PTSD
Disassociation and dissociative identity disorder (DID) are a defensive mechanism. They refer to a psychological and sometimes physical response to trauma, in which the individual disconnects.
This is often bound up in the stupor and emotional numbness that are features of depression. Disassociation is also common in people who have PTSD.
As with many other mental health conditions, it can be in varying degrees. You can have temporary symptoms of disassociation, or be diagnosed with a complex dissociative disorder.
It is not only diverse in its nature but also surprisingly common. Many people suffer from degrees of disassociation at some point in their life when a traumatic event causes them to temporarily ‘shut down’.
The term disassociation is often shortened to dissociation.
This article explores the topic of dissociation in more detail, including causes and potential therapies. Particularly focusing on the link between PTSD and dissociation.
Which comes first: PTSD or dissociation?
Experts in PTSD support and treatment believe disassociation is a common feature of post-traumatic stress disorder. The same events and experiences that cause PTSD, can result in the individual experiencing some degree of emotional detachment from reality. Therefore, dissociative behaviour could help diagnose PTSD, and vice versa.
However, there are occasions when the dissociation is not from the original trauma but develops over time as an escape from rumination and severe anxiety attacks. It becomes easier to ‘detach’ from the reality of their condition, rather than continue to relive the experience or cope with continuous mental anguish.
Disassociation can also be the point at which PTSD and depression overlap.
Symptoms and signs of disassociation
The way disassociation manifests varies from individual to individual, though it always involves some form of distancing from the traumatic experience, memory or source of anguish. It can occur in short bursts or last months or years.
Symptoms are broadly identity confusion, alternating identities, depersonalisation or a poor grasp of reality.
It can appear to be the loss of the sense of self or denial of personal history. The person may have difficulty remembering information about themselves or sometimes switch to different voices and names, and display erratic behaviour. They may have substantial gaps in recollection.
Also, a person who is dissociating could appear emotionally numb or divorced from all sensory experience. They express this as a dreamlike state, where the world is ‘foggy’ or blank, and what they see lacks defined shape, size or colour.
People with dissociative conditions sometimes feel like a robot or zombie. Or, they watch their own life as a TV programme.
All of these signs and symptoms show the disconnection between the individual and their memory, consciousness, identity and self-awareness.
Types of disassociation
Though each individual experiences a personal form of this mental health condition, according to the Diagnostic and Statistical Manual (DSM) Overview (extensively used by clinicians and psychiatrists) there are three categories of disassociation:
- Depersonalisation-derealisation disorder. This is when the individual becomes disconnected from their own thought process and physical functions. They can feel like they are watching themselves from a distance and have no control over their actions or surroundings.
- Dissociative identity disorder (DID). In the past, this was referred to as multiple personality disorder or a split personality. It’s when the individual switches between two or more personae.
- Dissociative amnesia. A type of disassociation in which the individual ‘wipes out’ memories of their own personal history and identity.
There is another often-cited type too – dissociative fugue. This is when someone travels to a new location, or takes on a new identity, unaware that they have transitioned from a previous life.
Dissociative identity disorder; myths and realities
The concept of multiple or split personalities has long fascinated the writers of fiction, helping to add to myths about dissociative identity disorder. One of the most widespread is that the individual can purposefully switch to completely separate personalities, one of which is an ‘evil’ or dangerous alter.
The truth about DID is far less definable. In most cases, the different identities are fragments of the individual’s own identity and switches are involuntary and undetectable to most observers. Even the individual can be unaware of their separation of identity.
Though people with DID may show signs of anger and violence, it is not an inherent trait of this mental health condition.
Other myths and misconceptions about dissociative identity disorder are that it is a form of pretence to escape consequences, or that it’s the same as schizophrenia (a psychotic illness involving delusions, paranoia and hallucinations).
The reality of DID is frequent amnesia, inability to recall personal information or past events, distress and confusion and inability to fulfil normal, everyday activities. They will express views, emotions and recollections differently, as they switch between identities. Either frequently or occasionally (such as when stressed).
Misdiagnosis and confusion
One of the few widely-respected books written about disassociation is ‘The Stranger in the Mirror: Dissociation – The Hidden Epidemic’ (2001), by Marlene Steinberg and Maxine Schnall. It’s based on case files of people with DID, which were part of a study by the Yale University school of medicine.
According to the authors: “Once considered rare, recent research indicates that dissociative symptoms are as common as anxiety and depression and that individuals with dissociative disorders (particularly Dissociative Identity Disorder and Depersonalization Disorder) are frequently misdiagnosed for many years, delaying effective treatment. In fact, persons suffering from Dissociative Identity Disorder often seek treatment for a variety of other problems including depression, mood swings, difficulty concentrating, memory lapses, alcohol or drug abuse, temper outbursts, and even hearing voices, or psychotic symptoms.”
One of the biggest problems in diagnosing dissociative disorders is that individuals can appear to function well at home and in their workplace. It is often only those who are closest to them, who see their struggles with reality, and disconnection from their own emotions and conscious actions.
The inability to feel normal emotion, grasp reality and enjoy healthy relationships can lead to the individual also developing self-loathing, low self-esteem, risk-taking behaviours and even suicidal thoughts.
Disassociation can be bound up with other underlying condition. This includes severe depression, acute stress disorder, borderline personality disorder (BPD), obsessive-compulsive disorder (OCD), substance misuse, sleep deprivation and eating disorders.
How common is dissociation?
Due to misdiagnosis, ambiguity in definitions and lack of research, the numbers of people who have chronic dissociative symptoms is unknown.
It is easier to measure DID – particularly when it manifests as more than one identity. According to SANE in Australia, research has shown it affects anything between 0.01% to 15% of the global population. Particularly as it’s prevalent in areas prone to wars, civil unrest or natural disasters. This national mental health charity also reports it’s more common in women than men, and usually develops in childhood as a response to violence and deep distress.
Can dissociation be a positive coping mechanism?
Steinberg and Schnall (2001), refers to disassociation as “an adaptive defence in response to high stress or trauma characterized by memory loss and a sense of disconnection from oneself or one’s surroundings.”
There are times when people with PTSD or other mental health conditions automatically disassociate themselves from the things they can’t control. Denial and disconnection become a calming mechanism, a way of switching off emotions temporarily to cope with a situation.
It is also a natural and instinctive defensive mechanism and survival technique, to help us cope when a trauma would otherwise be overwhelming and debilitating. An illustration would be someone who goes into a dissociative state after a car crash, who then remembers little or nothing about their rescue and trip to the hospital. They have defended themselves from intolerable fear, pain and helplessness. It may even have saved their life, keeping them calm, still and pliant.
This links to the way in which humans have consciously disassociated as part of religious or cultural practices. Putting their emotions into a neutral position and emptying their mind to achieve spiritual consciousness.
The problem comes when disassociation becomes habitual, long term or a way of ‘burying’ a trauma that did serious psychological damage such as in cases of PTSD.
Diagnosing dissociative conditions
Fortunately, the ways to diagnosis disassociation (at a level that is unhealthy) have become more advanced. This includes screening tools – such as the Dissociative Experience Scale.
Another common system to detect early indications of this condition is the Structured Clinical Interview for Dissociative Disorders (or SCID-D). Steinberg and Schnall (2001) said: “Over a hundred scientific publications by researchers in the United States and abroad have documented this test’s ability to accurately diagnose dissociative symptoms and disorders. In fact, research with the SCID-D indicates that the features of dissociation are virtually identical worldwide.”
However, such tools only demonstrate to a mental health clinician that the individual is showing symptoms of disassociation. A detailed diagnostic interview and talking therapies are used to gain a more thorough evaluation.
The aim of therapy for dissociation and PTSD is not to force the individual to immediately connect to the traumas they’re defending themselves from. Instead, its focus is connecting them to their current state, to build consciousness of their surroundings, physical sensations and safe environment.
Once they are more stable, the next stage would be to help them process the root causes of their PTSD and disassociation, in a supportive way.
Then, therapy would focus on empowering the individual to establish and maintain a cognitive and cohesive identity. Mindfulness techniques and talking therapies are often used to build this healthy level of awareness.
Medication for depression and anxiety may also be used, to stabilise the individual.
NICE guidance updated in 2018 recommends the use of trauma focused psychological treatments for Post Traumatic Stress Disorder in adults, specifically the use of Eye Movement Desensitisation Reprocessing (EMDR) and trauma focused cognitive behavioural therapy (CBT).
Please remember, these aren’t meant to be medical recommendations, but they’re tactics that have worked for others and might work for you, too. Be sure to work with a professional to find the best methods for you.
- Steinberg M, Schnall M: The Stranger in the Mirror: Dissociation-The Hidden Epidemic, HarperCollins, 2001, 2000.
- Dissociation and dissociative disorders
- Dissociative identity disorder (DID)
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