The diagnosis of dissociative subtype of posttraumatic stress disorder (PTSD) is made in patients who meet all the diagnostic criteria for PTSD and also experience persistent or recurrent dissociative symptoms (specifically, depersonalization and derealization) in response to a stressor. Diagnosis is based on history. Treatment consists of psychotherapy and medications.
(See also Overview of Dissociative Disorders and Posttraumatic Stress Disorder [PTSD].)
Some patients with PTSD experience prominent dissociative symptoms. Dissociation refers to incomplete integration of aspects of identity, memory, and consciousness, and is associated with unresponsive parenting and psychologic trauma, as well as with PTSD (1).
As with PTSD, dissociation commonly occurs in the aftermath of exposure to trauma, which may include experiencing the trauma firsthand, witnessing physical trauma experienced by someone else, learning of trauma suffered by loved ones, or being involved in the aftermath of trauma done to others (eg, as is required of emergency responders). Complex trauma, particularly that which occurs early in life and involves an intimate relationship (eg, with a caregiver), increases the likelihood of a patient developing PTSD with dissociative symptoms (2, 3).
In addition to a history of childhood sexual and physical abuse, other factors associated with dissociative symptoms later in life include physical violence, shame, and guilt (3).
A population-based survey from 16 countries reported that almost 15% of those with PTSD also had the dissociative symptoms of depersonalization and derealization (4). Patients with dissociative symptoms and PTSD were characterized by higher levels of re-experiencing symptoms, onset of PTSD in childhood, high exposure to trauma and childhood adversities (prior to PTSD onset), severe role impairment (eg, difficulties in performing job responsibilities and completing work around the house) and suicidality.
The neurologic mechanisms of different responses to trauma are being investigated. Experiencing sudden physical injury or the threat of it dysregulates emotion, causes hyperarousal of autonomic responses, and disrupts the continuity of a person's experience and expectations for the future. An analysis of functional MRI (fMRI) and PET findings among patients shows that the more common hyperarousal type of PTSD involves increased amygdala and anterior insula activity and decreased medial prefrontal and rostral anterior cingulate activity (5). As a result, cognition is overwhelmed by affect. In the dissociative subtype of PTSD, activations are reversed, leading to oversuppression of emotion consistent with depersonalization and derealization.
Although not all individuals who meet criteria for PTSD have high levels of dissociation, most patients with high levels of dissociative symptomatology meet criteria for PTSD (6).
General references
1. Ginzburg K, Koopman C, Butler LD, et al: Evidence for a dissociative subtype of post-traumatic stress disorder among help-seeking childhood sexual abuse survivors. J Trauma Dissociation 7(2):7-27, 2006. doi: 10.1300/J229v07n02_02
2. Dorahy MJ, Corry M, Shannon M, et al: Complex trauma and intimate relationships: The impact of shame, guilt and dissociation. J Affect Disord 147(1-3):72-79, 2013. doi: 10.1016/j.jad.2012.10.010
3. Dorahy MJ, Middleton W, Seager L, et al: Dissociation, shame, complex PTSD, child maltreatment and intimate relationship self-concept in dissociative disorder, chronic PTSD and mixed psychiatric groups. J Affect Disord 172:195-203, 2015. doi: 10.1016/j.jad.2014.10.008
4. Stein DJ, Koenen KC, Friedman MJ, et al: Dissociation in posttraumatic stress disorder: Evidence from the world mental health surveys. Biol Psychiatry 15;73(4):302-312, 2013. doi: 10.1016/j.biopsych.2012.08.022
5. Lanius RA, Vermetten E, Loewenstein RJ, et al: Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. Am J Psychiatry 167(6):640-647, 2010. doi: 10.1176/appi.ajp.2009.09081168
6. Wolf EJ, Miller MW, Reardon AF, et al: A latent class analysis of dissociation and posttraumatic stress disorder: Evidence for a dissociative subtype. Arch Gen Psychiatry 69(7):698-705, 2012. doi: 10.1001/archgenpsychiatry.2011.1574
Signs and Symptoms of Dissociative Subtype of PTSD
The dissociative subtype of posttraumatic stress disorder (PTSD) consists of all the symptoms of PTSD as well as depersonalization and/or derealization.
Symptoms of PTSD include intrusion symptoms such as involuntary memories, dreams, or dissociative flashbacks. Many people try to avoid remembering the events or physical reminders of them. They may develop negative alterations in cognition, including dissociative amnesia, feeling detached or estranged from others, inappropriate self-blame, and inability to experience positive emotions. Hypervigilance, irritability, difficulty concentrating, and sleep disturbance also occur.
Dissociative symptoms include disturbances of identity, memory, and consciousness (specifically, depersonalization and derealization):
Depersonalization: Persistent or recurrent feelings of detachment from one's mental processes or body (eg as if one were an outside observer of one's experience; feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).
Derealization: Persistent or recurrent experiences of unreality of one's surroundings (eg, the world around the individual is experienced as unreal, dreamlike, distant, or distorted).
Diagnosis of Dissociative Subtype of PTSD
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria for PTSD plus the presence of dissociative symptoms (specifically, depersonalization and derealization)
Medical and psychiatric examination to rule out other causes
To meet the diagnostic criteria for PTSD "with dissociative symptoms," an individual must meet the diagnostic criteria for PTSD and must also experience persistent or recurrent symptoms of either depersonalization or derealization in response to the stressor.
Treatment of Dissociative Subtype of PTSD
Modified approach to psychotherapy used for PTSD
Treatment should be modified from the common and effective therapies typically used for hyperarousal PTSD (prolonged exposure and cognitive processing); direct exposure may provoke further dissociation. The recommended therapeutic approach is staged psychotherapy involving gradual exposure; identifying dissociative symptomatology; stabilization, clarification, and discussion of dissociative symptoms; exploration of stressors that may lead to dissociative episodes; and controlling risk of revictimization (1, 2). However, the data are mixed and subsequent studies have suggested that the essential elements of exposure-based and cognitive reprocessing psychotherapies that are effective for PTSD may also work well with those who have prominent dissociative symptoms (3, 4).
Hypnosis may also be useful to help patients contain and reprocess traumatic memories. It may help patients maintain physical comfort, thereby using dissociation to protect them from unwanted arousal while altering their perspective on the traumatic experiences (eg, helping them recognize what they did to protect themselves or others during the trauma). This technique may enable them to both restructure their depersonalization and derealization experiences and learn control over their need for dissociation (5, 6).
Treatment references
1. Cloitre M, Petkova E, Wang J, et al: An examination of the influence of a sequential treatment on the course and impact of dissociation among women with PTSD related to childhood abuse. Depress Anxiety29(8):709-717, 2012. doi: 10.1002/da.21920
2. Resick PA, Suvak MK, Johnides BD, et al: The impact of dissociation on PTSD treatment with cognitive processing therapy. Depress Anxiety29(8):718-730, 2012. doi: 10.1002/da.21938
3. Burton MS, Feeny NC, Connell AM, et al: Exploring evidence of a dissociative subtype in PTSD: Baseline symptom structure, etiology, and treatment efficacy for those who dissociate. J Consult Clin Psychol ;86(5):439-451, 2018. doi: 10.1037/ccp0000297
4. Zoet HA, Wagenmans A, van Minnen A, et al: Presence of the dissociative subtype of PTSD does not moderate the outcome of intensive trauma-focused treatment for PTSD. Eur J Psychotraumatol 9(1):1468707, 2018. doi: 10.1080/20008198.2018.1468707
5. D Brom, R J Kleber, P B Defares: Brief psychotherapy for posttraumatic stress disorders. J Consult Clin Psychol 57(5):607-612, 1989. doi: 10.1037//0022-006x.57.5.607
6. Spiegel D: The use of hypnosis in the treatment of PTSD. Psychiatr Med10(4):21-30, 1992. PMID: 1289959
Prognosis for Dissociative Subtype of PTSD
The presence of dissociation complicates prognosis and treatment of this subtype of PTSD because many of these individuals distance themselves from confronting the effects of the trauma, which makes treatment more difficult to address (1).
Prognosis references
1. Koopman C, Classen C, Spiegel D: Predictors of posttraumatic stress symptoms among survivors of the Oakland/Berkeley, Calif., firestorm. Am J Psychiatry 151(6):888-894, 1994. doi: 10.1176/ajp.151.6.888
