Recent research demonstrates something trauma therapists already know: some people who meet the criteria for PTSD also experience symptoms of dissociation. They propose that there is a subtype of PTSD in which the client presents with chronic numbing rather than hyperarousal. This may be common among those who are elsewhere described as experiencing complex PTSD as a result of chronic trauma such as prolonged childhood abuse.
I think it is very important for clinicians to be aware of and able to assess for dissociative symptoms. I agree with the conclusion here that it is important to incorporate treatment of dissociation into the phases of trauma treatment as needed, and to recognize that different treatment approaches may be needed when numbing predominates.
Emotion Modulation in PTSD: Clinical and Neurobiological Evidence for a Dissociative Subtype
Ruth A. Lanius, M.D., Ph.D., Eric Vermetten, M.D., Ph.D., Richard J. Loewenstein, M.D., Bethany Brand, Ph.D., Christian Schmahl, M.D., J. Douglas Bremner, M.D., and David Spiegel, M.D.
Abstract: In this article, the authors present evidence regarding a dissociative subtype of PTSD, with clinical and neurobiological features that can be distinguished from nondissociative PTSD. The dissociative subtype is characterized by overmodulation of affect, while the more common undermodulated type involves the predominance of reexperiencing and hyperarousal symptoms. This article focuses on the neural manifestations of the dissociative subtype in PTSD and compares it to those underlying the reexperiencing/hyperaroused subtype. A model that includes these two types of emotion dysregulation in PTSD is described. In this model, reexperiencing/hyperarousal reactivity is viewed as a form of emotion dysregulation that involves emotional undermodulation, mediated by failure of prefrontal inhibition of limbic regions. In contrast, the dissociative subtype of PTSD is described as a form of emotion dysregulation that involves emotional overmodulation mediated by midline prefrontal inhibition of the same limbic regions. Both types of modulation are involved in a dynamic interplay and lead to alternating symptom profiles in PTSD. These findings have important implications for treatment of PTSD, including the need to assess patients with PTSD for dissociative symptoms and to incorporate the treatment of dissociative symptoms into stage-oriented trauma treatment.
Am J Psychiatry 2010; 167:640-647
(published online April 1, 2010; doi: 10.1176/appi.ajp.2009.09081168)
© 2010 American Psychiatric Association
Dr. Kathleen Young: Treating Trauma in Tucson 
Interesting study. I, too, have noticed dissociative features in my PTSD clients. I think classifying PTSD as a dissociative disorder makes more sense than classifying it as an anxiety disorder.
Debra Stang
Alliant Professional Networking Specialist
It seems to me that the concept of “Complex PTSD” is appropriate because anxiety and numbing go hand and glove. There would be no need to numb if the memory of the trauma didn’t cause too much pain, anxiety, depression, or lack of function. Many such survivors of childhood abuse spend much of their lives in a dissociated state and have no awareness of it until some of the anxiety/memory/ flashback finally pushes through the fog and presents a crisis – this is often the first clue that “something is wrong and I need help” for the survivor. It is frustrating to me that these labels are nearly as disruptive as a “segmented” mind; placing depression in one box, anxiety in another, panic disorders in a third, numbing… and so forth. Many survivors have all of these functioning at once, if not rotating in response to the current environment and known and unknown triggers. “Complex PTSD”, I find, is a good umbrella term that unites all of these aspects into something more people could understand, thus learning to treat comorbid patients and seeing this as a norm rather than a minority. I believe more could be accomplished once this was established and then treated with an integrative model of health.
Thanks
I’m Claire. 51, female, gay single now only, COPD.
I also have PTSD, major depression, etc. Early childhood violence.
I just would like to put my two cents in and agree to the dissociative theroy. It’s me.
Not bi-polar, but can have that manic blast. I manage it, or I don’t. Just a fyi. Thank you, Claire Yes, I see a therapist who has so many clients she needs help. But I’m living w/ it. Life is over, but I’m living with it.
I am sorry that has been your experience Claire. I wish for you therapy that helps you believe healing is possible, that life does not have to be over.
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Hi, I know I’m late commenting on this, but I have a question. What about those who experience both hyperarousal and dissociation? Have you seen this in your patients? I have hyperarousal (insomnia, angry outbursts, exaggerated startle response) but also dissociate (during therapy, intimacy, etc.).
Kristine- it is never to late. 🙂
You raise a very good point with your question. I often see clients who experience both. Hyperarousal and numbing/dissociation my alternate or occur dependent upon the situation. Some experience hyperarousal symptoms while dissociating the content (traumatic memory) that would help make sense of these symptoms.
I think this would make a good future article! Thanks for asking!
Thanks for answering! I appreciate it.
While it may help to create this subtype, I experience what’s described here:
Click to access Onno%20van%20der%20Hart.pdf
and
http://www.amazon.com/Haunted-Self-Dissociation-Traumatization-Interpersonal/dp/0393704017
There’s an increasingly complex combination of states in complex trauma involving different defensive action systems.
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