Dissociation/Derealisation and Self-harm

At the moment I am experiencing severe episodes of Dissociation and Derealisation culminating in extreme self-harm. I have increased my Psychotherapy sessions from two to three sessions a week for containment and am being assessed for admission to a Clinic. The Clinic Admission is problematic as the rules of the Clinic have changed with compulsory attendance at Group CBT sessions now mandatory. With my PTSD I cannot manage group sessions as I become triggered and have panic attacks. My Psychiatrist is trying to get an exemption from attendance at these sessions but no luck so far. It is getting to a critical stage as my Dissociation Identity Disorder and alters are getting out of control and my family desperately need respite from supervision. Our options for Clinics are limited as we live in rural Australia and Mental Health Services are poor. So what can we say about this Dissociation?

Dissociation—a common feature of post-traumatic stress disorder (PTSD)—involves disruptions in the usually integrated functions of consciousness, memory, identity, and perception of the self and the environment. Acute dissociative responses to psychological trauma have been found to predict the development of chronic PTSD. Moreover, a chronic pattern of dissociation in response to reminders of the original trauma and minor stressors has been found to develop in persons who experience acute dissociative responses to psychological trauma.

There may be 2 subtypes of acute trauma response that represent unique pathways to chronic stress-related psychopathology: one is primarily dissociative and the other is predominantly intrusive and hyperaroused.

The term “dissociation” has denoted a wide variety of phenomena encompassing both states and traits. Here I want to focus is on dissociative symptomatic responses to trauma-related stimuli in PTSD—particularly states of depersonalisation and derealisation. The questions I asked myself were:

• Did what I was experiencing seem unreal to me like I was in a dream or watching a movie or play?

• Did I feel like I was a spectator watching what was happening to me, like an observer or outsider?

• Did you feel disconnected from my body?

  • Did I feel like I was in a fog?
  • Complex post-traumatic stress disorder (C-PTSD) also known as developmental trauma disorder (DTD) or complex trauma is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma in the context of dependence, captivity or entrapment (a situation lacking a viable escape route for the victim), which results in the lack or loss of control, helplessness, and deformations of identity and sense of self. Examples include people who have experienced chronic maltreatment, neglect or abuse in a caregiving relationship, hostages, prisoners of war, concentration camp survivors, and survivors of some religious cults.”
  • Think of a child who is dependent on their caretaker to provide safety, nurturing, along with all their basic needs. If a child has been neglected – not attended to, and on top of that abuse – the child is in a no win situation. They have to have the adult take care of them, and yet, at the same time, they are being abused. It creates chaos in the child’s sense of self.
  • Research is showing that children who grow up in these kinds of households, brains actually develop differently. When we are babies our neuronal pathways are growing very rapidly. When we get “good enough” parenting, meaning that the caretakers are attuning to the baby needs emotionally on a consistent basis and providing the essential basic needs, the pathways grow, and as the baby grows up it begins to learn how to regulate emotional states. If the baby is growing up in an environment where the caretaker is emotionally not available, or even being abusive, the neuronal pathways actually shrink or die off. Similar to the phrase “use it or lose it”. When this happens you will see people grow up struggling with relationships, being successful in their jobs, or handling day-to-day stressors.
  • Through the process of experiencing so much early trauma, we may dissociate to protect ourselves from the disturbance. Dissociation is a way to not feel something. It is seen on a continuum, from where we drive our car somewhere and we realise, “how did I get here,” to fully detached state of Dissociative Identity Disorder, a diagnosis in the DSM-5. When something happens to us that overwhelm our system and we can’t process it we dissociate. I have six alters who at times control me tot he points that only they are present. This is a normal and natural process that occurs to protect us. We dissociate every day because it’s very difficult to be 100% present all day long.
  • As children, we may not have enough resources to handle certain experiences so the process of dissociation can occur to help us survive. As we grow up into adults, the same process of dissociation can occur because a pattern was set early on and so similar situations that remind us of the original situation trigger our brains to dissociate. As a child that process helped protect us but as adults it may actually get in the way of fully participating in our lives.
  • Dissociation can look like different things – people space out, want to run away, leave their body and watch themselves, get rageful, etc. It’s important that one becomes familiar with how they dissociate so they can learn to stay present as an adult.
  • The more complex the layering of traumatic events, the more we need to learn how to stay present in their bodies. With Complex PTSD, people struggle to stay connected to the present.
  • They can easily dissociate while trying to think of the traumas they experienced in their childhoods. Learning to find ways to stay present is essential in the Preparation Phase of EMDR Therapy. It’s helping the client stabilise emotional states so that you can stay present while reprocessing the old traumatic memories. You need to keep one foot in the present (I am in the room with my therapist) while looking at a past traumatic event. This process of dual attention is important to successfully healing a trauma. I need to have a witness to the event rather then just relive it and feel completely overwhelmed again.
  • Traditional EMDR Therapy treatment becomes more complex when working with Complex PTSD. This process of developing skills for the client to stay present in their body and minds is important for therapists to learn. Therapists sometimes have to become more creative in helping their clients develop these skills such as using drawing, music, nature as away into helping the client feel more positive and less distress in their lives.

Recent research evaluating the relationship between Post-traumatic Stress Disorder (PTSD) and dissociation has suggested that there is a dissociative subtype of PTSD, defined primarily by symptoms of derealisation (i.e., feeling as if the world is not real) and depersonalisation (i.e., feeling as if oneself is not real)

The disorder is usually triggered by severe stress, particularly emotional abuse or neglect during childhood, or other major stresses (such as experiencing or witnessing physical abuse).

Feelings of detachment from self or the surroundings may occur periodically or continuously.

After tests are done to rule out other possible causes, doctors diagnose the disorder based on symptoms.

Psychotherapy, especially cognitive-behavioural therapy, is often helpful.

Temporary feelings of depersonalisation and/or derealisation are common. About one fourth of people have felt detached from themselves (depersonalisation) or from the surroundings (derealisation) at one time or another. This feeling often occurs after people

Experience life-threatening danger

Take certain drugs (such as marijuana, hallucinogens, ketamine, or Ecstasy)

Become very tired

Are deprived of sleep or sensory stimulation (as may occur when they are in an intensive care unit)

Depersonalisation or derealisation can also occur as a symptom in many other mental disorders, as well as in physical disorders, such as seizure disorders.

Depersonalisation/derealisation feelings are considered a disorder when the following occur:

Depersonalisation or derealisation occurs on its own (that is, it is not caused by drugs or another mental disorder), and it persists or recurs.

The symptoms are very distressing to the person or make it difficult for the person to function at home or at work.

This disorder occurs in about 2% of the population and affects men and women equally.

The disorder may begin during early or middle childhood. It rarely begins after age 40.

Causes of Depersonalisation/Derealisation Disorder

Depersonalisation/derealisation disorder often develops in people who have experienced severe stress, including the following:

  • Being emotional abused or neglected during childhood
  • Being physically abused
  • Witnessing domestic violence
  • Having had a severely impaired or mentally ill parent
  • Having had a loved one die unexpectedly

Symptoms can be triggered by severe stress (for example, due to relationships, finances, or work), depression, anxiety, or use of illegal or recreational drugs.

Symptoms of Depersonalisation/Derealisation Disorder

Symptoms may start gradually or suddenly. Episodes may last for only hours or days or for weeks, months, or years. Episodes may involve depersonalisation, derealisation, or both.

The intensity of symptoms often waxes and wanes. But when the disorder is severe, symptoms may be present and remain at the same intensity for years or even decades.

Depersonalisation symptoms involve feeling detached from one’s body, mind, feelings, and/or sensations. People may also say they feel unreal or like an automaton, with no control over what they do or say. They may feel emotionally or physically numb. Such people may describe themselves as an outside observer of their own life or the “walking dead.”

Derealisation symptoms involve feeling detached from the surroundings (people, objects, or everything), which seem unreal. People may feel as if they are in a dream or a fog or as if a glass wall or veil separates them from their surroundings. The world seems lifeless, colorless, or artificial. The world may appear distorted to them. For example, objects may appear blurry or unusually clear, or they may seem flat or smaller or larger than they are. Sounds may seem louder or softer than they are. Time may seem to be going too slow or too fast.

The symptoms almost always cause great discomfort. Some people find them intolerable. Anxiety and depression are common. Many people are afraid that the symptoms result from irreversible brain damage. Many worry about whether they really exist or repeatedly check to determine whether their perceptions are real.

Stress, worsening depression or anxiety, new or overstimulating surroundings, and lack of sleep can make symptoms worse.

Symptoms are often persistent. They may

  • Recur in episodes (in about one third of people)
  • Occur continuously (in about one third)
  • Become continuous (in about one third)

People often have great difficulty describing their symptoms and may fear or believe that they are going crazy. However, people always remain aware that their experiences of detachment are not real but rather are just the way that they feel. This awareness is what separates depersonalisation disorder from a psychotic disorder. People with a psychotic disorder always lack such insight.

Diagnosis of Dissociation and/0r Depersonalisation/Derealisation Disorder

  • A doctor’s evaluation
  • Sometimes tests to rule out other possible causes
  • Doctors suspect the disorder based on symptoms. A physical examination and sometimes tests are done to rule out other disorders that could cause the symptoms, including other mental health disorders, seizure disorders, and substance abuse. Tests may include magnetic resonance imaging (MRI), computed tomography (CT), electroencephalography (EEG), and urine tests to check for drugs.
  • Psychologic tests and special structured interviews and questionnaires can also help doctors with the diagnosis.

Prognosis

Complete recovery is possible for many people, especially if the symptoms result from stresses that can be dealt with during treatment. Other people do not respond well to treatment, although they may gradually improve on their own. A few do not respond to any treatment.

Symptoms, even those that persist or recur, may cause only minor problems if people can keep their mind busy and focus on other thoughts or activities, rather than think about their sense of self. However, some people become disabled because they feel so disconnected from their self and their surroundings or because they also have anxiety or depression.

Treatment of Depersonalisation/Derealisation Disorder

Psychotherapy

Sometimes anti-anxiety drugs and antidepressants

Depersonalisation/derealisation disorder may disappear without treatment. People are treated only if the disorder persists, recurs, or causes distress.

Psychodynamic psychotherapy and cognitive-behavioural therapy have been effective for some people. Depersonalisation/derealisation disorder is often associated with or triggered by other mental health disorders (such as anxiety or depression), which require treatment. Any stresses that triggered the symptoms or that may have contributed to development of depersonalisation/derealisation disorder must also be addressed.

Techniques that can help include the following:

Cognitive techniques can help block obsessive thinking about the unreal state of being.

Behavioural techniques can help people become absorbed in tasks that distract them from the depersonalisation.

Grounding techniques use the five senses (hearing, touch, smell, taste, and sight) to help people feel more connected to themselves and the world. For example, loud music is played or a piece of ice is put in the hand. These sensations are difficult to ignore, making people aware of themselves in the present moment.

Psychodynamic techniques focus on helping people work through intolerable conflicts, negative feelings, and experiences that people feel they must detach themselves from.

Anti-anxiety drugs and antidepressants sometimes help, particularly if people also have anxiety or depression.However, anti-anxiety drugs may also increase depersonalisation or derealisation, so doctors carefully monitor use of these drugs.

In the meantime, I am just hanging in there getting through each day. I find the days I have EMDR helpful and the dissociation/derealisation lessens only to return that evening with a vengeance. It is conniving and devious. We have had so many visits to Accident and Emergency in the last three weeks for stitching it’s ridiculous.

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