Navigating Dissociation and PTSD
Living with the aftershocks of trauma can be a profoundly disorienting experience. For many, the complex interplay between Post-Traumatic Stress Disorder (PTSD) and dissociative symptoms adds an extra layer of challenge, often leaving individuals feeling disconnected from themselves, their bodies, and the world around them. When confronted with an overwhelming experience from which there is no physical escape—such as childhood abuse, long-term violence, or war trauma—the human mind can find an internal escape hatch through a psychological defense mechanism known as dissociation (Lanius et al., 2012; Simeon, 2022). While this response is a sign of immense strength and the impulse to survive, its long-term impact can lead to a fragmented sense of self and an interference with daily functioning (Spiegel et al., 2011). Navigating dissociation and PTSD can be a confusing, painful, and often misunderstood experience by both those living with and those treating those with dissociation and PTSD.
This blog post explores the intricate relationship between dissociation and PTSD. It clarifies the fundamental differences between depersonalization and derealization, provides a comprehensive overview of the dissociative diagnoses as classified by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5 TR), and delves into the lived reality of these conditions. It further highlights the need for a specific therapeutic approach, detailing a more gentle approach to Eye Movement Desensitization and Reprocessing (EMDR) as a model of treatment that prioritizes safety and attunement as paramount.
The Two Sides of Detachment: Defining Depersonalization and Derealization
Per Lanius and Wolfe, the dissociative subtype of PTSD affects an estimated 15% to 30% of individuals with the disorder and is primarily defined by symptoms of depersonalization and derealization (Lanius et al., 2012; Wolf et al., 2012). While they are often intertwined, these two experiences represent distinct phenomena:
Depersonalization is the experience of unreality or detachment from one’s own body, thoughts, feelings, or identity (Spiegel et al., 2011). Individuals with this symptom often feel as though they are an “outside observer” of their own actions and thought processes, a sensation also known as an “out-of-body” experience (Lanius et al., 2012). This psychological process creates the perception that “this is not happening to me,” which typically reduces the intensity of the emotional experience during the traumatic event itself (Lanius et al., 2012).
Derealization, by contrast, is an alteration in the perception of the external world (Simeon, 2022). People experiencing derealization feel as if their surroundings are unreal, distorted, or distant (Simeon, 2022). Just as with depersonalization, this state creates a mental and emotional buffer, leading to a perception that “this is not really happening to me” and is often associated with a decrease in emotional intensity (Lanius et al., 2012).
Research on the neurobiological basis of these two states suggests they are distinct from the hyperarousal responses typically associated with PTSD (Lanius et al., 2010; Lanius et al., 2012). While individuals who re-experience traumatic memories with hyperarousal exhibit reduced prefrontal cortex activation and increased amygdala reactivity, those with depersonalization/derealization show increased activation in the medial prefrontal cortex. This suggests that the dissociative response is mediated by a top-down inhibition of the limbic regions, a kind of neural self-anesthetization, while hyperarousal is a failure of this inhibitory control (Lanius et al., 2012). And this self-anesthetization makes sense for those living with dissociation. They may tell you that it often happens in response to very painful memories or being triggered into a painful flashback. Would you want to have surgery without an anesthesiologist on hand? No is the answer. Flashbacks to trauma memories that are so horrific as to feel that they are being re-experienced in real time need to be squashed. This self-anesthetization (or dissociation) becomes the mechanism by which this is done.
To provide a clearer picture, the following table summarizes the key distinctions:
| Feature | Depersonalization | Derealization |
| Focus of Detachment | The self, body, and emotions (Simeon, 2022; Spiegel et al., 2011) | The external world and surroundings (Simeon, 2022) |
| Experience | Feeling like an outside observer, robotic, or disconnected from one’s own body (Spiegel et al., 2011) | The world feels unreal, foggy, distant, or dreamlike (Simeon, 2022) |
| Metaphors | Out-of-body experience, watching oneself in a movie (Lanius et al., 2012) | Living in a simulation, a dream, or through a glass barrier |
The Fragmentation of Self: DSM-5 TR Dissociative Disorders
Beyond the dissociative subtype of PTSD, the DSM-5 TR recognizes a spectrum of dissociative disorders that involve a profound disruption in consciousness, memory, identity, and perception (Spiegel et al., 2011; American Psychiatric Association, 2022). These conditions are considered to be a defense mechanism against trauma, enabling individuals to detach from painful emotions or memories (Simeon, 2022). The primary types of dissociative disorders are: Dissociative Identity Disorder (DID), Dissociative Amnesia, and Depersonalization/Derealization Disorder (American Psychiatric Association, 2022).
- Dissociative Identity Disorder (DID): Formerly known as multiple personality disorder, DID involves the presence of two or more distinct identities or “personality states” (Spiegel et al., 2011). It is a common misconception that people with DID display “multiple personalities” (Gillig, 2009). Instead, it is a fragmentation of one’s core identity. These distinct identities, each with their own memories, behaviors, and preferences, may take control of the person’s conduct at any given time, leading to significant distress and functional problems (Spiegel et al., 2011). A key symptom is ongoing gaps in memory regarding everyday events, personal information, and past traumatic events (American Psychiatric Association, 2022). DID is strongly associated with repetitive, overwhelming, and often chronic trauma during early childhood, such as severe physical or sexual abuse (American Psychiatric Association, 2022). As a clinician who has come to know clients’ living with DID, I see this process as the body’s incredible capacity to persevere life for the survivors of repeated, horrific abuse. It is quite remarkable the brain and body will create this fragmentation to cope, survive and manage in an often chaotic and confusion world of repetitive abuse.
- Dissociative Amnesia (DA): This is characterized by an inability to recall important personal information, usually of a traumatic or stressful nature, that is inconsistent with normal forgetfulness (Markowitsch & Staniloiu, 2012). This memory loss is not caused by a medical condition or substance use and is a core survival tactic used to avoid emotional distress and anxiety associated with the trauma (Simeon, 2022). A notable and rare subtype is dissociative fugue, which involves sudden, unexpected travel away from home with a loss of customary identity and bewildered wandering (Markowitsch & Staniloiu, 2012). I have worked with some clients who have experienced dissociative fugue. It is confusing, scary and, often, life threatening for the individual in a fugue state.
- Depersonalization/Derealization Disorder (DPDRD): This disorder is diagnosed when the experiences of depersonalization and/or derealization are persistent or recurring and cause significant distress or impairment in social or occupational functioning (American Psychiatric Association, 2022). While many people may have brief, isolated experiences of detachment, in this disorder, the dreamlike state becomes constant and disruptive to daily life (Spiegel et al., 2011). I have worked with clients where this diagnosis has been separate from any, identifiable trauma history.
The Lived Reality of Dissociation: A Different Kind of Pain
To truly understand the challenges of living with dissociation, it is essential to move beyond clinical definitions and engage with the subjective, day-to-day experience. The fragmentation of memory and identity creates a profound and constant sense of confusion and struggle (Lebois et al., 2022). Individuals with dissociation often feel like they are “chasing stability” while constantly stepping into “unknown versions of themselves,” which creates significant self-puzzlement and difficulty trusting in relationships (Lebois et al., 2022). The fragmentation of self makes basic tasks difficult, as crucial information, such as important contacts, may be lost (Markowitsch & Staniloiu, 2012). The constant sense of being “unreal” or separate from the world is deeply distressing and can lead to intense feelings of shame, guilt, and worthlessness (Spiegel et al., 2011). And not knowing is even more challenging, meaning many with severe dissociation are misdiagnosed over-and-over again. They think, “I’m going crazy” or “the noise is too much” (referencing the internal fragmented landscape of alters commenting on daily life). When with a client I feel may be living with dissociation I might say, “does it ever feel like there is an audience of others in your head commenting on your actions and negotiating for you?” When the answer is, “yes!,” it confirms the lived reality of dissociation (at severe levels) to be a confusing and complex reality. But it doesn’t have to be. When embraced, we can find the root of the reason for dissociation and learn to understand, seek compassion and learn to live again.
The Unique Attunement Required for Dissociation
Due to the fundamental differences in their psychobiological responses, individuals with a dissociative presentation of PTSD require an approach to therapy that is distinct from traditional, exposure-based models (Resick et al., 2012). The trauma that leads to dissociation is often chronic and relational, such as childhood abuse or neglect, which instills a deep inability to feel safe in relationships and a view of oneself as “damaged” and “unworthy of care” (Lebois et al., 2022). Therefore, the therapeutic relationship itself is not just a container for healing but a primary vehicle for it (Lebois et al., 2022). Let me repeat that! THE THERAPEUTIC RELATIONSHIP IS THE PRIMARY VEHICLE FOR HEALING!
This is where the concept of dissociative attunement becomes central. Attunement is a “synchronized awareness” between client and clinician, a “profound rhythmic encounter” where the clinician acts as a “microtonal tuning fork” that can resonate with the subtle, “nuanced shifting of emotional tone” (Lebois et al., 2022). This process is nonlinear and can paradoxically appear to be misattunement, as the therapist may be resonating with a deeper, unarticulated part of the client’s experience that is not consciously expressed. The therapy is not just about what the therapist does to help a client process a memory, but about how the therapist is in relation to the client’s fragmented self (Lebois et al., 2022).
An example would be if I am with a client and I sense severe dissociation may be present for the client. I may shift the tonality of my voice, perhaps (for example) to match the energy being projected towards me. Maybe I sense younger energy than the chronological age of the client and I may use a therapeutic tone or approach for that age. When it is met with visible relief from the client and a “you get me,” we have identified a high likelihood of parts. The goal is to demonstrate that it is possible to feel safe and cared for within a relationship. This is a novel experience for most living with severe dissociation.
Pacing the Path to Healing: A Gradual Approach to EMDR Therapy
Eye Movement Desensitization and Reprocessing (EMDR) is a widely recognized and effective therapy for trauma (Resick et al., 2012). However, its standard protocol is not helpful for most people with dissociative disorders because of the risk of “flooding,” where the rapid processing opens up too many traumatic memories at once, which is overwhelming and unsafe for a fragmented system.
This is why a modified method for EMDR needs to be used. The Progressive Approach (Dolores Mosquera and Anabel Gonzalez, 2012) is one such method. At its core, the philosophy of this approach is “slower is faster.” It is a clinical embodiment of the therapeutic principles of attunement and safety. Since dissociation is a protective mechanism that separates traumatic information into different neural networks or “parts,” a therapy that forces a rapid, full-scale integration would be re-traumatizing. The progressive approach counters this by “turning around” the standard EMDR process. Instead of starting with the core trauma memory (“the palm”) and branching out, it begins with small, manageable “tip-of-the-finger” memories on the periphery. (Mosquera & Gonzalez, 2012).
The therapist works collaboratively with the client to process tiny fragments of memory, emotion, or thought that are associated with the trauma but are less overwhelming. This is often called “parts work,” where the therapist helps the client connect with and “re-parent” these dissociated parts-of-self. The therapist helps these parts, which cannot tell the difference between “then and now,” to “time orient” to the present day, where there are resources and safety. This slow, deliberate process allows the client to process trauma in digestible pieces while strengthening the “adult self” and building internal trust between the parts of their system.
In contrast to the basic EMDR protocol, the progressive approach radically shifts how EMDR works, making sure the client can tolerate reprocessing with any steps necessary. This is when EMDR is a tool used as an art form. The goal of the progressive approach is honoring the brain’s original protective strategy and working slowly to build internal cooperation. There is a greater chance for this to help individuals with complex trauma and dissociation find coherence where there was once only fragmentation.
Living with dissociation and PTSD can feel like navigating a fractured reality, but healing and understanding are possible.
By understanding the nuances of dissociative experiences, seeking out therapists who are specifically trained in working with dissociation, and prioritizing a safe and attuned therapeutic approach, individuals can gradually reclaim their sense of self and find a path toward wholeness. Practical strategies can also provide a sense of control and grounding. Grounding exercises, which help to reconnect with the present, are invaluable tools. Mindfulness meditation, which encourages staying in the moment and observing thoughts and feelings without judgment, also helps to foster self-awareness and emotional regulation. In addition, learning coping tools, like the conference room and parts maps, can also help more fully understand ones system.
The journey of healing is a profound act of courage and resilience. This journey, while painful, is not one of weakness but a profound demonstration of the impulse to survive and the strength to rebuild a coherent sense of self. With the right tools and professional support, individuals can find their way out of the unreality and back into a life of connection, stability, and peace.
References
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