Are PTSD and C-PTSD dissociative disorders? Does it matter?

art-1699977_1920Are PTSD and C-PTSD dissociative disorders?  Yes, but it’s more important to remember that they are first of all about terror.

It appears that PTSD and C-PTSD may be grouped under the dissociative disorders in the next edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders).  As Matthew Friedman points out, the new DSM-5 category of trauma and stress related disorders was intentionally placed next to the dissociative disorders in order to suggest their similarity (p. 549).  Whether this is a good direction to be heading is another question. 

A quick definition: dissociation is the division of parts of the self.  Dissociation occurs when the parts of the self that know and feel traumatic experience no longer communicate with the rest of the self.  Dissociation is generally seen on a continuum, more or less.   

What’s dissociative about PTSD and C-PTSD?  

I’ll get to C-PTSD (complex PTSD) in a minute. 

It’s easy enough to interpret the leading symptoms of PTSD in terms of dissociation.  The flashback is a dissociative symptom, a failure to prevent intrusion of unwanted and painful experience.

PTSD criteria read like a short laundry list of dissociative isolative and exclusionary processes (intrusion, numbing, and avoidance). (Chefetz, p. 28)

The dissociation associated with PTSD is characterized by an alteration between hyperarousal and numbing or constriction.  The dialectic of trauma moves between intrusion and numbing.   

Judith Herman (pp. 47-49) and others have argued that the experience of trauma generally moves from early hyperarousal to later numbing and constriction.  Others, such as Richard Chefetz see no progression, just the dominance of one position or another. 

Some people with PTSD present with flooding, and others are so emotionally shutdown that they present as emotionally flat, detached, with active dissociative process.  (p. 80)

What’s useful about seeing PTSD and C-PTSD in terms of dissociation?

I’m not so sure it is useful.  Chefetz argues that

PTSD criteria have a dissociative engine under the hood. (p. 189) 

Intrusions like flashbacks are non-integrated experiences, and by definition dissociative in nature.  Avoidance or constriction is provoked by intrusions of trauma-related thought. 

PTSD is essentially a kind of dissociative disorder with a trauma criterion tacked on. (p. 189)

This way of looking at PTSD raises problems.  It confuses the defense with the threat.  The value of PTSD is that it reminds us that the world itself intrudes upon us, threatening everything we hold dear: the lives of friends and family, as well as our own.  The world itself becomes unpredictable and out of control.  In response we are terrified.  In focusing upon an external cause, PTSD reminds us that the world is a cruel and frightening place for many people. 

Dissociation is the response to terror, the defense.  It would be more accurate to say that PTSD has terror under its hood.  Terror drives us to split off parts of ourselves in order to survive.  Dissociation is the defense against terror.  Trauma is terror.  Chefetz and others, such as Onno van der Hart, risk confusing the defense with the cause.     

Early terror, the terror of abandonment and lack of parental attunement to our needs as infants and children, to say nothing of abuse and neglect, leads to C-PTSD, in which dissociation becomes salvation.  With it we can escape an inescapable and unbearable situation by leaving part of ourselves to the terror, while another part lives on.  Unfortunately, this survival strategy often becomes a way of being, a way of life.  Sometimes we don’t even know it. 

The difference between PTSD and C-PTSD

In one important respect, PTSD and C-PTSD are on a continuum, the continuum of terror.  Both are responses to unbearable situations.  But they are different responses, and this is one occasion in which I think neuroscience can be helpful.  As Matthew J. Friedman points out

regarding the dissociative subtype, findings with functional magnetic resonance imaging (fMRI) among individuals with PTSD and dissociative symptoms, showed a reversal of the usual fMRI pattern, marked by excessive prefrontal cortical activity associated with reduced activity in the amygdala. (p. 553)

In other words, people with C-PTSD are often less overtly anxious and aroused (as signaled by an over-active amygdala) because they have successfully dissociated or separated the terrorized parts of themselves into a separate part of the self (van der Hart et al.).  This is not without cost, as it makes large parts of the self unavailable for the delight of living.  But it helps explain how some people with terrible traumas, not just abused children, but Holocaust survivors, for example, manage to live what appear to be normal lives. (see http://www.traumatheory.com/holocaust-survivors/)

Sometimes the terror returns.  More often, life just seems to be flat, empty, missing something.  For many this absence is worth its price if the alternative is terror.  Many don’t even think about it.  That’s the point. 

The price and what it buys

To see PTSD as a dissociative disorder risks missing the main point.  PTSD is about fear, ultimately the fear of loss of attachment to all relationships we value: relationships of love and friendship, as well as relationships to values.  Dissociation is the defense, and while it is useful to understand the defense, Chefetz, like van der Hart, risks deemphasizing the cause.  One sees this when Chefetz writes about PTSD as if it were some sort of dissociative identity disorder (DID).   What this leaves out is what PTSD brought to the table in the first place: the recognition that some experiences are unbearable.

What the focus on dissociation adds is a more complete explanation of why people who undergo terrible experiences so often seem to reenact them, even if it’s just holding onto what they would desperately be rid of.

I see the problem of repetition of trauma as less a compulsion to repeat what is unresolved and more a need to make sense out of disparate elements of experience using the only means available when thinking and feeling are blocked by dissociative process: action.  (Chefetz, p. 44)

Dissociation divides us into pieces, but the pieces are not strewn about in our minds.  They touch and overlap enough so that the compulsion to repeat can be seen as a desire to put together what we would desperately keep apart.  Because these pieces are unintegrated with the speaking, narrating self, enacting the trauma becomes a way of trying to tell the story.  Sometimes this is dangerous, especially in the case of sexual and other abuse.  Generally words are better.     

Conclusion

One reason it’s important to remember that fear—terror—drives PTSD is that otherwise the tendency is to assume that people who are prone to dissociation (and people vary significantly along this dimension), are more vulnerable to PTSD.   It may be true, but trauma is always a subjective response.  It doesn’t matter if some are more prone to dissociation. 

Trauma is the infliction of an unbearable reality.  Period.  Dissociation is how we bear the unbearable.  In that sense, dissociation is good.  Treatment is necessary when dissociation robs us of the joy of living, as if we were watching other people’s lives through a darkened glass.  Treat the defense, but respect the trauma, for it is the most real thing of all. 

References

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).  American Psychiatric Association, 2013. 

Richard Chefetz, Intensive Psychotherapy for Persistent Dissociative Processes: The Fear of Feeling Real.  W. W. Norton, 2015.  

Matthew J. Friedman, Finalizing PTSD in DSM-5: Getting here from there and where to go next.  Journal of Traumatic Stress, 2013, 26, 548–556.  

Judith Herman, Trauma and Recovery.  Basic Books, 1997.

Onno van der Hart et al.  Dissociation: An insufficiently recognized major feature of complex PTSD.  Journal of Traumatic Stress, 2005, 18 (5).  www.onnovdhart.nl/articles/jts_complex_%20ptsd.pdf

 

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