Editor's Note: This article discusses reactions to trauma and may be triggering for some readers.
"The public's unfamiliarity with dissociative symptoms and inability to identify them has caused dissociation to become the silent epidemic of our time. Besides all the people who have an undetected dissociative illness, there are countless others who've been diagnosed with the wrong illness."
--Marlene Steinberg, MD and Maxine Schnall, The Stranger in the Mirror: Dissociation -- The Hidden Epidemic
Recently, I’ve been pleased to see that many of my younger clients know a lot about dissociation, mainly from viewing social media. They recognize descriptions of dissociation in themselves and seek help. But for a long time, dissociation has been misunderstood by the public and professionals alike. Mental health professionals often do not ask about dissociative symptoms in their patients (Steinberg & Schnall, 2001). Clients rarely bring it up or lack the language to describe the experience. When this occurs, clients may end up with a diagnosis that only addresses a part of their true experience.
For some clients, receiving a diagnosis can be very helpful. A diagnosis can provide recognition that they are not alone; their experiences are common enough to fall under a defined name and category. It can feel validating. For this reason, I discuss some of the diagnoses a survivor experiencing dissociative hypoarousal might look out for (APA, 2013; van der Hart et al., 2006; van der Kolk, 2014). I also discuss some of the shortcomings of these diagnoses. Even so, like many trauma experts, I encourage survivors to consider themselves as suffering the long term effects of a psychological injury rather than as “mentally ill” (e.g, Levine, 1997).
To tell whether dissociative hypoarousal lies beneath mood and anxiety diagnoses, trauma experts recommend looking for evidence of a splitting of the self due to trauma (van der Hart, etl al., 2006). Dissociative hypoarousal shares many characteristics with depression. Both can involve lack of motivation, difficulty identifying emotions. loss of enjoyment, and social withdrawal. Clinicians may mistake a survivor's tendency to vascillate between hyper- and hypo-arousal for mood swings, leading to a bipolar disorder diagnosis. People who experience dissociative hypoarousal may describe themselves as highly anxious, while instead appearing calm or lacking in energy. When trauma lies at the root of mood or anxiety disorders, these diagnoses alone fail to get to the root of the problem.
Other trauma survivors may have received a personality disorder diagnosis, most often Borderline Personality Disorder (BPD). If a person diagnosed with BPD has a trauma history, many of their symptoms can be explained as manifestations of splits in the self. For example, mood swings may reflect shifts between trauma parts and non-trauma parts. Feelings of emptiness and a lack of sense of self can be explained by a fragmented self due to trauma. Impulsiveness, extreme anger and suicidal behaviors can occur due to trauma parts taking over unexpectedly.
Many survivors of trauma, students of psychology, and therapists recognize the diagnoses of depersonalization/derealization disorder, and dissociative amnesia as examples of mental illnesses that involve dissociation. Clinicians may select these diagnoses for clients who eperience alterations of consciousness and memory loss. Again, if these symptoms occur in reaction to trauma, they can be understood as manifestations of a split self.
In discussing splits due to trauma with my clients, some wonder if they may have dissociative identity disorder (DID). DID, marked by rigid splits in the self due to trauma, often does include dissociative hypoarousal. Although many trauma survivors have “parts'' within, most do not meet criteria for DID. DID and other rare dissociative disorders that involve a loss of identity including dissociative fugue have been the subject of fascination in movies and television series. Unfortunately, the dramatic focus on these illnesses, and misinformation about them, overshadows other forms of dissociative hypoarousal that appear more frequently in clients (Steinberg & Schnall, 2001).
Unlike many diagnoses I mentioned up until now, one particular DSM-V diagnoses does acknowledge the role of trauma. Specifically, dissociative hypoarousal occurs in the context of posttraumatic stress disorder (PTSD), which includes a dissociative subtype. However, trauma experts have noted that the PTSD diagnosis does not accurately match the experiences of most of the clients coming into their offices (van der Kolk, 2014). They found that quite often, clients suffered due to repeated traumatic events occurring over a long period of time. Many clients especially experienced PTSD-like symptoms following childhood abuse or neglect.
In response, trauma experts proposed the following diagnoses that, to date, have not been added to the DSM. These include complex post-traumatic stress disorder (C-PTSD), disorders of extreme stress, not otherwise specified, (DESNOS), and developmental or attachment trauma. Developmental trauma refers to trauma that directly affects a child’s social, emotional and biological development. Attachment trauma is a subtype of developmental trauma that specifically refers to events that occur in the first two years of life. In general, the earlier and more frequently a person experiences trauma, the more heavily they rely on dissociative hypoarousal to cope.
Although dissociative hypoarousal is an important survival strategy for trauma, perpetual dissociative hypoarousal blocks individuals’ ability to live full lives. It restricts joy, curiosity, creativity and the ability to engage fully in relationships. In these instances, therapy can help. Finding an accurate diagnosis can aid trauma survivors looking to understand their experiences. It can provide a jumping off point for self-awareness and therapeutic change. Because the DSM relies heaviily on symptoms to make diagnoses, finding one may mark only the beginning of recovery. When addressing dissociative hypoarousal, it helps to look more deeply than at mere symptoms. Identifying a trauma history and splits in the self brings a trauma survivor even closer to a path for healing.
In my next article, I begin to discuss the language of dissociative hypoarousal. in the hopes that it will improve survovors' ability to communicate their experiences to themselves and others.
The content of this blog is for informational purposes only and is not intended to diagnose, treat, cure, or prevent any condition or disease. This blog is not intended as a substitute for consultation with a licensed practitioner. Please consult with your own therapist or healthcare provider regarding any suggestions and/or recommendations made in this blog. Although the author has made every effort to ensure that the information in this blog was correct at publication time and while this publication is designed to provide accurate information in regard to the subject mater covered, the author assumes no responsibility for errors, inaccuracies, omissions, or any other inconsistencies herein and hereby disclaim any liability to any party for any loss, damage, or disruption caused by errors or omissions. Unless otherwise indicated by name or direct reference, any resemblance to persons, living or dead, or actual events is purely coincidental. The use of this blog implies your acceptance of this disclaimer.
The following sources were invaluable in writing the above article:
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
Levine, P.A. (1997). Waking the Tiger: Healing Trauma. North Atlantic Books.
Steinberg, M. & Schnall, M. (2001). The Stranger in the Mirror: Dissociation — The Hidden Epidemic. Harper.
Van der Hart, O., Nijenhuis, E.R.S., & Steele, K. (2006). The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization. W.W. Norton.
Van der Kolk, B. (2014). The Body Keeps The Score: Brain, Mind, and Body in the Healing of Trauma. Penguin Books.