As they say in The Music Man, “You can talk all you want…but you gotta know the territory.” To really understand what peritraumatic dissociation is all about, you gotta know the territory — namely, peritraumatic dissociation’s historical context and its role in several important debates.
About a decade before peritraumatic dissociation was ‘discovered’ in California. [Where else! :-)], Russell Noyes published a series of articles about “transient depersonalization syndrome” (Noyes, Hoenk, Kuperman & Slyman, 1977). Noyes was a near-death researcher; he studied motor vehicle accident victims and those who had experienced near-drownings, near-fatal falls, heart attacks, and so on.
A significant proportion of Noyes’ subjects reported that their brush with death was characterized by a sense of detachment, unreality, time-slowing, emotional calm, and accelerated thought. Noyes, by the way, was the scholar who retrieved, translated, and republished Heim’s (1892) account of the experiences of mountain climbers who had survived potentially fatal falls. As we noted in an earlier post, Heim’s mountain climbers who fell had experienced the same phenomena that Noyes described.
Because there had been little academic interest in dissociation for decades, Noyes’ articles about near-death depersonalization experiences largely ‘took place in a void.’ There was no ‘hook’ on which to hang his findings — except the fringe area of near-death experiences. Hey! It was the seventies!
The Battle Over PTSD
During the late 1960s and the entire 1970s, the Veterans Administration treatment system was flooded with Vietnam veterans who were angry, emotionally reactive, and haunted by recurrent memories and flashbacks about their time in Vietnam. The diagnosis of PTSD did not yet exist (it would not enter the DSM until 1980).
Prior to 1980 (and afterwards, as well) an intense political battle surrounded the diagnosis and treatment of Vietnam veterans. The ‘old guard’ claimed that these veterans were largely psychotic and that they should be treated as such. The ‘new wave’ insisted that these veterans were suffering from “Post-Vietnam syndrome,” a consequence of their wartime trauma. The ‘old guard’ would have none of it. They insisted that war does not cause mental illness — unless the soldier had a preexisting psychological problem or weakness.
A lengthy political battle ensued. The new wave won the debate and Posttraumatic Stress Disorder became part of the DSM. Prior to that, however, opponents of PTSD sought to minimize the number of PTSD diagnoses by seeking a restrictive Criterion A (which defines trauma in PTSD) in DSM-III. They lost that battle, too. DSM-III’s Criterion A for PTSD was quite broad. It defined trauma as:
“a recognizable stressor that would evoke significant symptoms of distress in almost everyone.” Criterion A further stated that a trauma is a stressor that “is generally outside the range of usual human experience.” (DSM-III)
The important point about this DSM-III definition of trauma is that it suggests that traumatic events will cause PTSD “in almost everyone.” Time and research data has shown that assumption to be incorrect.
Across all kinds of trauma, only about 25% of trauma survivors succumb to PTSD. Some kinds of trauma (e.g., physical and sexual assault) produce higher levels of PTSD. Nevertheless, it is now crystal clear that trauma (even rape) does not cause PTSD “in almost everyone.”
As a consequence of such findings, the DSM-IV Criterion A is much more restrictive:
“(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person’s response involved intense fear, helplessness, or horror.” (DSM-IV, emphasis added)
Notice that Criterion A2 requires a specific peritraumatic reaction (Aha! Peritraumatic reaction!). The person is required to experience “intense fear, helplessness, or horror” at the time of the traumatic event. In part, this peritraumatic diagnostic requirement is designed to distinguish between the 25% of trauma survivors who develop PTSD and the 75% who don’t.
The Trauma Field’s Belated Interest in Dissociation
During the struggle to define and defend PTSD, the trauma field had little interest in dissociation. In fact, it is probably accurate to say that the trauma field was actively disinterested in dissociation. After all, dissociation is weird and it’s connected to multiple personality disorder which is even weirder. Certainly, few paid much attention to Noyes’ articles about “transient depersonalization syndrome.”
Then fate took a hand. Card-carrying members of the trauma field discovered that many trauma victims dissociated during trauma: e.g., Are Holen (1993), David Spiegel (1991), Charles Marmar (1994). More importantly, Holen’s (1993) longitudinal study of the survivors of a North Sea oil rig disaster found that dissociation during the disaster predicted the subsequent development of PTSD. With that, the trauma field suddenly developed an interest in what quickly came to be called peritraumatic dissociation. This interest dove-tailed with the effort to define trauma and traumatization in terms of peritraumatic emotional reactions (Remember “intense fear, helplessness, or horror”?).
But the ambivalence of the trauma field about dissociation soon returned — for two reasons. First, as we have discussed in previous posts, research on the relationship between peritraumatic dissociation and PTSD has produced inconsistent findings. Second, Acute Stress Disorder became a lightning rod for attacks on dissociation.
Acute Stress Disorder
Amid the interest about peritraumatic reactions, a new diagnostic entity was born: Acute Stress Disorder.
According to the DSM diagnostic criteria, PTSD cannot be diagnosed unless the person has been symptomatic for 30 days. Thus, even if trauma survivors were intensely symptomatic during the 30 days after the trauma, they could receive no diagnosis or treatment until reaching the 30-day mark. This ‘gap’ in the nosology led David Spiegel and colleagues to propose a new diagnostic entity that would ‘fill the gap’ between the day of the trauma and PTSD’s 30-day diagnostic requirement.
Spiegel’s proposal was accepted (mostly) and DSM-IV ushered in a new diagnosis — Acute Stress Disorder. Unlike PTSD, a diagnosis of acute stress disorder requires that a person be very symptomatic for only 2 days (but for less than 4 weeks). Why less than 4 weeks? Because 4 weeks + 2 days = 30 days; at which point, a symptomatic person could receive a diagnosis of PTSD.
So what does acute stress disorder have to do with peritraumatic dissociation? A great deal. Spiegel was one of the fathers of peritraumatic dissociation (Spiegel, 1991). Acute stress disorder is the direct progeny of peritraumatic dissociation. In fact, Spiegel originally proposed that this disorder be called “Acute Dissociative Disorder.”
In keeping with this idea, Spiegel proposed a set of diagnostic criteria that emphasized dissociative symptoms. His proposed diagnostic criteria were mostly accepted, but his proposed name was not. Opponents said that the name made little sense because a person would have a dissociative disorder (Acute Dissociative Disorder) for a few weeks and then, suddenly, would switch to having an anxiety disorder (PTSD). Accordingly, the disorder was named acute stress disorder and, like PTSD, classified as an anxiety disorder.
The diagnostic criteria for acute stress disorder (ASD) are quite similar to those of PTSD (i.e., reexperiencing symptoms, avoidance symptoms, and hyperarousal symptoms), but with the addition of dissociative symptoms. Overall, ASD has fared reasonably well in subsequent research, but its dissociative diagnostic criteria have not. Just as peritraumatic dissociation has been an inconsistent predictor of PTSD, so too, have the dissociative symptoms of ASD proved to be an inadequate predictor of PTSD (e.g., Bryant, 2007; Marshall, Spitzer & Liebowitz, 1999).
The Territory of Peritraumatic Dissociation
Over the last 35 years, the territory of peritraumatic dissociation has ranged from (a) near-death experiences (Noyes’ transient depersonalization syndrome), to (b) the question, “Does peritraumatic dissociation predict PTSD?” (Answer: Not very well), to (c) the shift from the question, “What is a trauma?”, to the question, “What constitutes traumatization?” (According to DSM-IV: peritraumatic emotional reactions [i.e., “intense fear, helplessness, or horror”]), to (d) inspiring the creation of a new diagnostic entity (acute stress disorder).
My own contribution to this territory consists of asking two questions: (1) “What is peritraumatic dissociation, really?” and (2) “How much of it is a normal, hard-wired animal defense?” We will take a closer look at these two questions in my next post.
Aw, c’mon Dr. Dell…
This statement is such a stretch, it’s not even remotely close to apples and oranges. Keep it apolitical, and you’ll keep your readership… (and I’m an independent)
“A lengthy political battle ensued — one not unlike the battle over the Obama administration’s health care program.”
You think my political views are showing, huh? They probably are. That is too bad because the size and intensity of the battle over PTSD was truly immense. That battle did not involve the general public, but it was so fierce that it provoked congress to fund a whole second system of treatment for Vietnam veterans — the veterans rap centers. It also generated an ongoing political battle over the definition of trauma — for fear that too many vets could qualify for treatment of PTSD and for disability status based on PTSD, thereby costing the government billions of dollars. In this respect, a scientific issue (PTSD and its treatment) became a political football.
Yes, they are! No reason to further irritate political opponents when we are all on the same side here, regarding strengthening mental health care. I won’t even go into how the new bill will adversely affect those of us here in NM… that belongs on a political blog.
I would totally validate your accounting of what occurred with legitimizing PTSD, but I would add that this is not cause to open the door to a much different scenario re: current health care battles.
Again, not even in the same ballpark as apples and oranges.
I realize this is an off-topic question, but as your email address isn’t listed I figured I’d do it here…
Do you know of any resources for lay people/clients on the sort of severe, post-catatonic dissociative states you’ve talked about previously in your blog? (I’m forgetting the exact term- but basically where the body/brain/CNS shuts down due to immient death). I’ve encountered someone whose experiencing them for the first (remembered) time (she almost certianly had them as a child, but…) and would like to help find her some info to explain them to her to make them less frightening. Thank you.
i don’t have a ready resource to point you towards. IMO, your friend should see a dissociation-savvy therapist who can help her with what you are describing.
Thank you so much for the clarity of your explanations, I have thoroughly enjoyed your writings!
you wrote, ““Does peritraumatic dissociation predict PTSD?” (Answer: Not very well)”.
and i asked myself: does any one thing predict anything as complex as ptsd, in psychology? and answered, “not very often”. from this, i thought, just because peritraumatic dissociation at the time of a traumatic event does not predict ptsd (very well), it does not mean it is never important. for example, i think a critical variable might be whether the person also continues to dissociate post-trauma. thus, some people will “cope” by (the automatic, and yes i believe hard-wired capacity of) “dissociating” during an overwhelming, traumatic event, and then “snap out of it” once they are safe again. if, for many reasons (including constitutional/ temperamental, psychological, historical and social-systemic factors) the person who has survived a traumatic event is able to “feel and deal” with their experience of the traumatic event, and eventually give it meaning, then peritraumatic dissociation would have been a gift that helped them avoid ptsd, much like anaesthesia during surgery can help with post-surgery recuperation. by contrast, if (for the same list of reasons, above), the person is not able to feel, deal and make sense of the traumatic event, then “peritraumatic dissociation” could become a habit of mind that now becomes a part of “posttraumatic dissociation”, and the person ends up cycling between “avoidance and numbing” (i.e. dissociation) and “reliving and re-experiencing”.
(btw, this “cycling” between states of hyperarousal and hypoarousal is beautifully captured in two quotes of yours, above: states: “… characterized by a sense of detachment, unreality, time-slowing, emotional calm, and accelerated thought”, and becoming “… angry, emotionally reactive, and haunted by recurrent memories and flashbacks…”)
I’m still having a problem with finding a ‘yes’ or ‘no’ answer in any of this. It seems to me that peritraumatic dissociation can vary in a lot of ways, and the person experiencing it also contains many characteristics that vary. Then there’s the nature of the trauma – another variable.
I think there is a biological underpinning that get activated in some situations and with some people in peritraumatic reactions. The nature of how much or how little could begin to sound like the old nature/nuture debates, only in this case it would involve resilience, attachment models, severity of trauma as perceived by the victim, the availability, or lack thereof, of community support, etc.
I don’t think there would be enough occasions of peritraumatic dissociation to study the phenomena if there weren’t a biological basis for it.
Looking at the people I’ve worked with, including Vets, there does seem to be a learned quality with the people who have had previous trauma. It’s as if the body already knows things can get really, really, bad, so dissociation gets triggered immediately. For people who haven’t been previously traumatized, that first time seems to stand out in vivid, non-dissociated intensity and they can’t get away from it. The following traumas, however, get foggy really fast. It’s never the same as the first one, and I think that’s a combination of biology and learning.
@paul: I would be glad to see your next post.
It means so much to me that you dedicate yourself to understanding PTSD and the phenomenon of disassociation. I’ve been PTSD since childhood, and wish I could have had access to this information long, long ago. The symptoms are so unsettling, unusual and frightening, and the worst part growing up was not understanding why I felt so strange. Knowledge is power. I look forward to your future posts and to keep learning about myself!