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Dissociative Subtype of Posttraumatic Stress Disorder


David Spiegel

, MD, Stanford University School of Medicine

Reviewed/Revised May 2023

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.

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 Depersonalization/Derealization Disorder Depersonalization/derealization disorder involves a persistent or recurring feeling of being detached from one’s body or mental processes, like an outside observer of one's life (depersonalization)... read more ), 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...

  • In complex trauma, a child is exposed to multiple traumatic events, often in the form of child abuse or neglect. It differs from PTSD, which can result from one exceptionally traumatic event.

  • Because a trusted caregiver is usually involved in complex traumas, the child’s neurocognitive development, sense of self, and ability to form secure attachments is disrupted, which often has consequences into adulthood.

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.

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