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

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.     


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. 


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).



Comments (2)

  1. Integrationinprogress

    I always thought I was functional. No anxiety or depression to speak but there was a dark space now and then. Loss of memory here and there. Just a bit of a dreamer, I would justify.

    Until recently.

    I came out in my therapy and demanded engagements, demanding that he does not let me stay in trance and just basically sort of out of control (but respectful way) of stating this free association thing does not work for me. I am not neurotic and I do not have anxiety and he cannot just sit there and watch me disappear. I have time lapse issues and free association is sort of making me lose more time. I even said to him, are not you feeling dead inside listening to me, cause I am dead listening to myself? I was sort of pushing him to use his counter-transference since transference of dissociated person is sort of obvious in therapy!

    Well he was gum-smacked! He is a new therapist but he has good enough empathy for me to work with. I do not expect him to be expert but there is a point right?
    I rather have supportive, empathic therapist than a raging bull who wants me to wake up before I know I am sleeping.

    Now, here you said:
    “People with C-PTSD are often less overtly anxious and aroused (as signalled 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.” BINGO! and these are why a lot of people from Holocaust became successful in medicine, therapy and psychology. Because we those suffering C-PTSD completely separated from what I call “baby needs selves”. Completely! And our functional self can be so good and so successful that we may never question if anything is missing until luckily something happens…a crisis or extreme health (somatic) issues or not.

    Of course I am in therapy and that day was probably the best day in therapy for me. I went home and for the first time, felt the switch from that baby demanding self (I was basically demanding love, attachment, touch etc. as a baby) but of course as an adult it came out like hey therapist, you do not listen to me, you are not attune to me, you are bored because I am dying here…disintegrating. It must have been awkward for a therapist to see an adult talking baby needs like that but this is the nature of the work.
    The weird thing though was this: right in the middle of my baby self-part rant, I would just shut off here and there go back and forth between my narrative, everyday functional self that I know and this baby self part that is ranting in the therapy room. At the time, I would say, hold, my brain is shutting off and I would look confused. It did not dawn on me until I get home I was going back and forth in functional self-part and baby needs self-part. My husband saw me looking like I was in a panic and said, are you worried seeing your family next week? Boom. I was out of the baby self-part and back fully in my functional self-part. He told me long time ago, I act different around my family and I heard but did not understand what he was talking about. This day I get it. That ranting baby-self-part that was in the therapy room and walked into this apartment was the self-part that shows up in my family gatherings and with my mother. I am in terror, in panic in fear for my life around my family but when I am out and about other places, I am functional. I never seen these two self-parts so back to back until I was in therapy. In the past, I just avoided my family unless I was really in a good mood as much as I could and after I leave, I would take the biggest sigh like inhale a balloon of oxygen cause I was probably holding my breath the hole time and did not know about it. Just relief!

    This just happened last week. The first time, I can feel my functional self in comparison to my baby-needs-self part (asking for love, attunement etc). Since then I also identified two other baby parts – one distraction (boredom) this is usually no energy and is the path to the panic self-part to take over. There is also angry self-part that seethes inside and hardly comes out but can be heavy to carry and rants alone after the facts of what made me angry. These are the internal works for a person who was basically in Stockholm situation with my own mother. I have had enough transference to know that most of my traumas at the baby level were un-attunement and negligence and lack of love rather than the abuse that came after I started to talk but nevertheless for my baby self – that was too much to bear as you said it. After I talked, I was abused relentlessly.
    I know now that I have at least the following baby self parts and adult self part:
    Panic baby self-part – it shows up as extreme anxiety and fear of psychosis and can be super defensive and negative. Shows up in therapy and in transference but I am conscious right after it happens, usually. It is not aggressive just extremely fearful, terror!
    Angry baby self-part – it shows up angry and defensive and argumentative as well as avoidant. Hardly shows up in therapy but the functional of me gives stories about it.
    Distracted baby self-part – this is the full dissociation part of me. It shows up as tiredness and boredom and I can read 20hrs and not realize the time. It also shows up in free association and when I go into trance in therapy; hence why I fought back to change the process of therapy or leave this therapy. Did not know it shows up in therapy until last week, when I panicked and thought I was going to psychosis or death.

    And then there is the functional self with no health issues whatsoever and now I am becoming a bit more aware about my baby-self-parts, I am extremely sad I did not know I was crying from my baby parts but now I am compassionate to myself. I really get me finally. When I am functional, I can write a lot and I can empathise a lot and life is easy and I do not need meditation. Actually, I wonder why people need meditation if they can this self part? The only time I need meditation is when my babyparts self are taking over me. I am light when I am back to functional self. Never knew the distinction until now.

    What I want to learn more about now are the object relations for each baby part-self to fully understand myself. I know those that split off from me but I am yet looking to understand how they relate to objects.
    My functional is happily married but without knowing my baby parts internal objects, I am sort of missing some limbs.
    In my view of myself, my functional self was exile for so long, it does not have full ownership of me. My panic (which I try to hide of course) but comes out to people in such that I am hyper, I am a trouble maker, I am blunt!!! Sort of way and I would be all the time, I am none of those. Because I did not know how my baby-part-selves act when they are on the reign of the self.

    Work in progress.


    Dear work in progress, I think you describe the experience of dissociation well, and that C-PTSD, with its emphasis on dissociation is a good framework. You sound like you are quite aware of what you are experiencing. When I woke up to my dissociation I was more confused and less reflective.

    I’m glad your therapist is helping, and I’m glad you find C-PTSD a useful category. Fred

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