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Dissociative Disorder: a Subtype of Posttraumatic Stress

We now know that those who suffer posttraumatic stress disorder don't have to be soldiers who endured war trauma. The event itself isn't in itself the issue. Rather, it is how our body responds to the incident, our body's ability to process and heal, that leads to signs and symptoms of posttraumatic stress. I often talk about complex posttraumatic stress (#cPTSD) as well, because these are people who maybe can't identify any one specific traumatic event, but live with significant stress on a daily basis and overtime create the same changes in the brain and central nervous system who have suffered profound trauma. Now let me introduce the dissociative subtype of posttraumatic stress disorder (PTSD+DS), which describes about 13 to 30 percent of those with posttraumatic stress.


Interestingly, there does seem to be a genetic predisposition to those who suffer PTSD+DS, and evidence suggests that risk factors are prior trauma, childhood adversities, and childhood onset of PTSD. If you're a client of mine, then you've had access to our Detoxification & Wellness program within which we offer six weeks of education on trauma, as this is an important component of healing and optimizing health. Here we talk about the amygdala's role in trauma and how it adapts, particularly in chronic states of stress, to better identify threats in effort to protect us. This keeps us in a rather heightened state of awareness however, and causes our more rational brains to shrink in size. Those with a history of trauma have very different neural activation throughout the brain. We fire differently.



There are a number of dissociative disorders or mental disorders which involve experiencing a disconnection and lack of continuity between thoughts, memories, surroundings, actions and identity. People with dissociative disorders escape reality in ways that are involuntary and unhealthy and cause problems with functioning in everyday life.


Those who experience significant trauma, particularly childhood trauma, certainly may need to detach, separate, and bury their experiences in effort to cope, maybe even survive. We use to say that our brain blocks out memories of trauma to protect us, and sometimes we disconnect from ourselves to get through. Consider that when individuals are raped, they often have an out-of-body experience. They separate from themselves and feel sorrow for the person experiencing this horrific event. In time, most people come back into themselves, but others really struggle to relate to themselves, losing touch with who they are and failing to identify with their own personality. My own mother can only remember a handful of memories from her entire childhood, and those she does remember were traumatic in themselves. Children are much more able to step outside of themselves and observe trauma as if it is happening to another person, and as they age, they can continue using this coping mechanism in response to stress.


When we consider a diagnosis of dissociative disorder for individuals, we look for memory loss of certain time periods or events, maybe even people or personal information. There maybe a sense of being detached from yourself or your emotions. The perception of people and things around you may be distorted and unreal, or they may have a blurred sense of identity. Almost always these people have significant stress and problems with their relationships, struggle at work and in other important areas of their lives. They have real inability to cope well with emotional and professional stress, and may also have #depression, #anxiety, or suicidal thoughts and behaviors.


Some people with dissociative disorders present in crisis with traumatic #flashbacks that are overwhelming or associated with unsafe behavior. People with these symptoms should be seen in an emergency room. If you or a loved one has less urgent symptoms that may indicate a dissociative disorder, please connect with your primary care provider. If you have thoughts of hurting yourself or someone else, call a suicide hotline number such as the National Suicide Prevention Lifeline at 1-800-273-8255 to speak with a trained counselor.


These individuals more often also suffer self-harm or #mutilation, sexual dysfunction, #alcoholism or drug abuse, depression and anxiety, personality disorders, insomnia, nightmares, sleepwalking, eating disorders, or even have seizures or lightheadedness.


What research has more recently taught us is that there are two different ways in which emotion is regulated in those with posttraumatic stress. This is also true of how our #amygdalas process information, we have two sorts of pathways, either undermodulation (PTSD-DS) and overmodulation (PTSD+DS). These are heavy in scientific verbiage, but I offer this for those who are really digging into the science on the amygdala. If that is less of an interest to you, skip down to the three types of dissociative disorders.


Emotional Undermodulation


This scenario consists of reliving traumatic experiences with related hyperarousal, characteristic of non-dissociative individuals with PTSD (PTSD-DS). The prefrontal cortex regions of the brain are not nearly as activated as would normally occur, nor is the anterior cingulate cortex. This leads to decreasing top-down inhibition of the amygdala and hyperactivation of the limbic system.


Emotional Overmodulation


In contrast to that above, overmodulation is more an emotional detachment and hypoarousal which includes depersonalization and derealization, characteristic of PTSD+DS. Overmodulation is thought to be modulated by increased prefrontal cortex and anterior cingulate cortex activation, resulting in excessive top-down inhibition of the amygdala. Neuroimaging has shown us that the dorsal component of the amygdala is under active with emotional overmodulation which is thought to be related to autonomic blunting associated with emotional numbing and dissociation.


The Amygdala


This is the aspect of our brain, in the very center, that manages our fight-or-flight response. We can divide the amygdala into two subsections as well, the basolateral and centromedial complex. These two areas have different patterns of functional and structural connectivity, in addition to having unique roles in fear processing, which are altered in posttraumatic stress disorder individuals.


The basolateral evaluates sensory information and mediates cortical integration of fear and other emotions. It is regulated by feedforward inhibition from the medial prefrontal cortex via somatostatin connections, with outputs to the thalamus, striatum, and prefrontal cortex.


The centromedial complex is involved in the execution of fear responses, with GABAergic outputs to the brainstem and periaqueductal gray involved in descending pain modulation. This part of the brain also receives thalamic projections and mediates major nociceptive pathways. The deactivation of the centromedial complex results in the impairment of fear expression and acquisition. The connection between the basolateral and centromedial complexes are greater in those with PTSD+DS than it is in those with PTSD-DS.


Three Major Dissociative Disorders Defined


There are three major dissociative disorders defined in the diagnostic and statistical manual of mental disorders (#DSM-5), one being dissociative amnesia. The main symptom here is memory loss that's more severe than normal forgetfulness and that can't be explained by a medical condition. These individuals can't recall information about themselves or events and people in their lives, especially from a traumatic time.


Dissociative amnesia can be specific to events in a certain time, such as intense combat, or more rarely, can involve complete loss of memory about themselves. It may sometimes involve travel or confused wanderings away from their life (dissociative fugue). An episode of amnesia usually occurs suddenly and may last minutes, hours, or rarely, months or years. This can also be a sort of emotional numbness.


Dissociative identity disorder, formerly known as multiple personality disorder, is characterized by "switching" to alternative identities. They may feel the presence of two or more people talking or living inside their head, and they may feel as though they're possessed by other identities. Each identity may have a unique name, personal history and characteristics, including obvious differences in voice, gender, mannerisms and even such physical qualities as the need for eyeglasses. There also are differences in how familiar each identity is with the others. People with dissociative identity disorder typically also have dissociative #amnesia and often have dissociative #fugue.


Depersonalization-derealization disorder involves an ongoing or episodic sense of #detachment or being outside yourself - observing of their own actions, feelings, thoughts, as well as self from a distance as though watching a movie (#depersonalization). Other people and things around you may feel detached and foggy or dreamlike, time may be slowed down or sped up, and the world may seem unreal (#derealization). You may experience depersonalization, derealization or both. Symptoms, which can be profoundly distressing, may last only a few moments or come and go over many years.


Treatment for Dissociative Disorders


Talk therapy is important (psychotherapy) although medication may prove necessary as well. Treating these disorders can be difficult, but learning new coping mechanisms for leading healthy, productive lives is doable. Seek a therapist with experience in trauma as not all therapists really are equipped to handle this issue. You don't have to talk about the trauma as much as you'll work to learn healthy coping skills.


Within talk therapy, cognitive behavioral therapy may be offered or dialectical behavioral therapy. In some cases, eye movement desensitization and reprocessing (#EMDR) is used to help identify pathways of trauma, triggers, and create new pathways of coping.


No specific medications treat dissociative disorders, although antidepressants, anti-anxiety, and antipsychotic drugs can help control other diagnosis that often accompany dissociative disorders. Somatic therapy is imperative, which helps those who have detached from their own bodies and inner child, reconnect and become more embodied.


This can be hard to identify until it is and then it can be a very eye-opening awareness. Let me be clear though, this is not attention seeking behavior though. Those with dissociative disorders do not desire these behaviors and are just as distressed as those who love them, and they are often unaware this even exists. Connect with your primary care provider if this resonates with you and you'd like to gain more resources and tools, but don't forget somatic healing in your plan for healing.


References

Modesti, M. N., Rapisarda, L., Capriotti, G., & Del Casale, A. (2022). Functional neuroimaging in dissociative disorders: A systematic review. J. Pers. Med, 12(9), 1405.

Nicholson, A. A., Densmore, M., Frewen, P. A., Theberge, J., Neufeld, R. W. J., McKinnon, M. C., & Lanius, R. A. (2015). The dissociative subtype of posttraumatic stress disorder: Unique resting-state functional connectivity of basolateral and centromedial amygdala complexes. Neuropsychopharmacology, 40(10), 2317-2326. doi: 10.1038/npp.2015.79

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