Dissociation, PTSD Risk, And Childhood Trauma

Dissociation — a sense of being detached from one’s own body, thoughts, and feelings — can be a common response to physical or psychological trauma. As such, it’s often observed in people with post-traumatic stress disorder (PTSD). The exact relationship between these psychological reactions to trauma is still debated within the psychological literature. However, research suggests that there could be a significant overlap between the dissociative response and some symptoms of PTSD.

Dissociation during traumatic events appears to increase a person’s risk of developing PTSD, and dissociative responses afterward may predict greater symptom severity. Experiences such as intense flashbacks in response to PTSD triggers may be partly enabled by dissociation. Some neurobiological evidence points toward a subtype of PTSD marked by strong dissociative symptoms, such as a loss of connection to the self and the world. PTSD and symptoms like dissociation can often be treated with various types of therapy.

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What is dissociation?

Dissociation generally refers to a psychological state in which an individual senses they are disconnected or detached from some aspects of their experience. This can take many forms, but all of them tend to involve a subjective impression of separation, distance, or diminishment. 

Some forms of dissociation may be mild and benign. For example, the feeling of “losing yourself” in a daydream or losing track of the flow of time while driving may be forms of non-pathological dissociation. However, severe dissociation can be highly distressing, potentially leading to consequences like isolation, relationship challenges, fear or worry, and difficulty functioning in everyday life.

Clinical evidence suggests that dissociation may play a role in generating or worsening other symptoms of serious mental illness. A 2021 paper found that dissociative symptoms can be linked to:

• Psychotic symptoms, such as hallucinations
• Cognitive disorganization
• Grandiosity (an exaggerated sense of importance or power)
• Paranoia
• Anxiety
• Depression
• Post-traumatic stress symptoms

Dissociative disorders

A dissociative disorder can be defined as a mental health condition characterized primarily by severe dissociative symptoms. The American Psychiatric Association recognizes three such disorders:

• Dissociative identity disorder: This disorder is what many people call “multiple personality disorder.” An affected individual may shift between two or more personas with distinctive speech patterns, behaviors, and thinking styles. Sometimes, this is accompanied by gaps in memory.
• Dissociative amnesia: This can refer to the loss of personal memories, such as forgetting a specific time period or sequence of events. In rare cases, dissociative amnesia can involve forgetting one’s entire identity and personal history.
• Depersonalization/derealization disorder: This disorder usually involves ongoing or repeated sensations of detachment from one’s body, actions, or sense of identity, or a persistent or recurring sense of unreality. 

Trauma, dissociation, and PTSD

Not all cases of dissociation have clear causes, but researchers have found that they tend to be especially common in people who have had traumatic experiences. Childhood abuse and other severely distressing early-life experiences appear to be particularly likely to lead to dissociative symptomatology. Other kinds of events that may lead to dissociation include sexual assault, physical violence, natural disasters, and serious accidents

Mental health experts on the relationship between dissociation PTSD risk and childhood trauma

Many mental health experts believe that dissociation may result from the mind’s attempt to protect itself from extreme physical or emotional pain. By mentally distancing themselves from threats they can’t avoid or fight, people who dissociate might avoid becoming overwhelmed in dangerous situations. 

This response can be helpful for immediate survival, but it may have harmful long-term consequences. Dissociation during or immediately after trauma can be linked to a higher risk of PTSD. This effect could be due partly to negative beliefs arising from dissociation. For instance, dissociative responses may lead to immobility during traumatizing events, potentially contributing to a sense of guilt in the survivor because of their seemingly passive response. 

The dissociative PTSD subtype

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) recognizes a distinct subtype of posttraumatic stress disorder called “PTSD with dissociative symptoms” or d-PTSD. It’s typically marked by frequent occurrences of depersonalization (a sensation of detachment from one’s own body or mental processes) and derealization (sensing that the surrounding world is distant or unreal). 

A 2022 meta-analysis estimated that between 22% and 48% of people with PTSD may exhibit the d-PTSD subtype. It seems to be more common in children but can affect adults as well, especially those who have experienced significant levels of trauma early in life. The Clinician-Administered PTSD Scale (CAPS), a tool frequently used to evaluate individuals for post-traumatic stress, includes items meant to assess the presence and severity of dissociation.

Controversy surrounding d-PTSD

Some researchers dispute the existence of a dissociative subtype of PTSD. For example, a 2019 study found little evidence that people with dissociative symptoms responded differently to therapies for PTSD. 

Another paper argued that dissociation is a risk factor for all forms of PTSD, and, therefore, isn’t specific enough to one subcategory.

However, other evidence indicates that the dissociative subtype may be a diagnostically useful category. Evidence gathered from World Mental Health Surveys indicates that dissociative symptoms in PTSD can be associated with several specific features setting these cases apart from others, including a greater likelihood of the following:

• Experiencing the onset of PTSD in childhood
• Being male
• Having a high exposure to childhood adversity and other forms of trauma before PTSD onset
• Experiencing severe difficulties fulfilling social roles
• Experiencing suicidal thoughts and behaviors

In addition, there’s some clinical and neurobiological evidence that people with this PTSD subtype may show different physiological responses to trauma triggers. When most people with PTSD encounter triggers, they exhibit a heightened heart rate and increased activity in the amygdala — a brain region associated with fear processing — as well as diminished activity in the prefrontal cortex. These responses tend to be consistent with heightened activity in the sympathetic nervous system (the “fight-or-flight” response). 

However, studies show that the opposite responses usually occur in people with dissociative PTSD. Some researchers believe this indicates that dissociation arises partly as a self-regulatory response, counteracting the hyperarousal of the sympathetic nervous system to protect against the effects of prolonged stress.

Dissociation and PTSD symptom severity

Dissociation may directly influence other symptoms of PTSD. A 2022 paper concluded that people who exhibited signs of dissociation soon after experiencing trauma could be likely to develop more severe cases of PTSD. These individuals frequently showed higher levels of depression and anxiety, as well as more functional impairment. 

Another study in the Journal of Trauma & Dissociation found that, during PTSD treatment, changes in the severity of dissociative symptoms often predicted changes in other symptoms. Patients whose dissociation was successfully treated were usually more likely to show other markers of recovery.

Certain kinds of symptoms classically associated with PTSD may be rooted in dissociation. For example, “flashbacks,” in which the individual temporarily loses awareness of their present circumstances and senses they have been transported back to a traumatic memory, are often considered a type of dissociative experience. 

Dissociation and complex PTSD

Another potential subtype of post-traumatic stress disorder is complex PTSD or cPTSD. While it’s not recognized by the DSM-V, the International Classification of Diseases (ICD-11) acknowledges it as a distinct category. This form of PTSD is thought to be associated with repeated or prolonged experiences of trauma, such as abuse throughout childhood, rather than singular experiences, such as surviving a car crash or a bombing.

The proposed characteristics of cPTSD include severe emotional, cognitive, and interpersonal difficulties. Dissociative symptoms may also be particularly common in cPTSD, reflecting a dysfunctional coping response to complex trauma. Some studies show that people diagnosed with this form of PTSD tend to exhibit higher scores on assessments like the Dissociative Experiences Scale (DES). 

How are dissociative PTSD symptoms treated?

Current PTSD treatment standards tend to emphasize the use of psychotherapy in overcoming trauma-related symptoms. Medications may sometimes be used as secondary treatments, though many researchers believe options like benzodiazepines could worsen dissociative symptoms due to their hypnotic effects (inducing sedation and promoting sleep).

Some theories suggest that certain types of psychotherapy may be less effective for PTSD with dissociative symptoms. According to this view, therapies that involve confronting traumatic memories might be less effective because dissociation could reduce the patient’s emotional engagement. As a result, they might benefit less from this form of therapy.

However, the evidence for this difference in treatment effect is limited. A 2020 meta-analysis of existing research found no indication that people with dissociative symptoms responded differently to common trauma-focused therapies for PTSD. 

Mental health services and treatments for post traumatic stress disorder

According to the American Psychological Association, the most strongly recommended treatments for PTSD are:

• Trauma-focused cognitive-behavioral therapy (TF-CBT)
• Cognitive processing therapy (CPT)
• Cognitive therapy for PTSD (CT-PTSD)
• Prolonged exposure therapy (PE)

Other therapies that may be beneficial for some patients include the following:

• Eye movement desensitization and reprocessing (EMDR)
• Narrative exposure therapy (NET)
• Brief eclectic psychotherapy (BEP)

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Online therapy for dissociation PTSD risk and childhood trauma

If you’re having difficulty finding a treatment provider near you who specializes in trauma-focused therapy, you might want to try seeking care online. Internet therapy can sometimes make it easier to find a mental health professional with whom you can form a strong connection, which may have a significant effect on how well you respond to treatment.

Though more research on the topic may be needed, evidence suggests that online therapies can work well for those impacted by trauma. A review paper from 2016 concluded that based on current evidence, internet-based cognitive-behavioral therapy was an effective treatment for PTSD.