Trigger Warning: Dissociation, anxiety, depression, eating disorders and trauma.
Madeleine Crutchley speaks to Dr Judy Lightstone about dissociation, a disorder which can appear when people are stressed or anxious. (Illustration by Kiki Hall)
At the beginning of this year, I felt pretty familiar with most of my anxiety symptoms. They were still scary, and definitely among my least favourite physical sensations to experience, but I had developed ways to cope with them and ride out any intense waves of panic. However, after a particularly bad infection that sent my health into a momentary spiral, I began to experience some more distressing symptoms.
I had vertigo and dizziness, which were accompanied by short episodes where I felt that I was not really in my body. That latter symptom was one I had quite a bit of difficulty explaining to those around me. I felt detached from my movements, and my senses really dulled, as if I was watching myself move through a screen. It was especially noticeable when I looked at my hands; I felt as if someone else was moving them and I was watching passively from inside or outside my head. When that sensation would come over me, I found myself rubbing my hands together, stamping my feet against the ground or jumping to clutch something. Everytime I would attempt to describe the physical sensation (or lack of physical sensation), I would trail off, feeling conscious of how bizarre it sounded.
When those symptoms persisted, causing me even more anxiety, I dropped in to see my doctor who has become quite familiar with my symptoms. After a few tests, he confirmed that the dizziness was a textbook anxiety symptom and that what I was feeling was an ‘out-of-body’ experience. He gave me a bit of information about depersonalization, derealization and ‘grounding’ and then sent me on my way (telling me these episodes were a mild case of dissociation). The techniques of grounding that he mentioned to me largely focused on stimulating my physical senses; he told me to taste and smell strong flavours, have someone else touch my arm, and list out the things I could see in my surroundings. Since my doctor gave me that reassurance and those techniques, those symptoms have largely subsided and I feel pretty well equipped to deal with the short episodes. However, I was surprised that I hadn’t known about these cases of mild dissociation; he outlined that they were quite common in people suffering from anxiety.
In the effort to find out a bit more about dissociation, I spoke to Dr. Judy Lightstone. Dr. Lightstone has worked in the field for 40 years and was most recently the Director of the Auckland PSI Institute. She is no longer accepting clients, but has offered her expertise in this interview, to hopefully dispel some of that Google misinformation.
Can you explain the different types of dissociative disorders? What are symptoms that make up derealization/depersonalization?
Dissociation occurs, in my opinion, on a continuum. It might start with one traumatic incident that would cause a very simple split where the person has a part of the self that deals with the day to day issues and another part of the self that re-experiences the trauma. That part is vulnerable to be triggered by things in the environment that set off memories of the trauma. When that happens the person goes into what we might call a dissociative state, where they regress, relive the trauma, forget that they’re in the present for a little while and not function very clearly. You could also say that both states are dissociative because in order to be functioning very well in the present and acting as if everything is fine you’ve got to split off the trauma. That would be considered very basic dissociation.
Then there are more complex types of dissociation, where the trauma occurs younger. If there’s more than one trauma or ongoing trauma (such as child abuse), there can be different parts of self re-experiencing different types of abuse. Different parts of self can be triggered in the environment by a lot more things. The most extreme form of dissociation is caused by very early and extreme trauma. That’s when you get the more dramatic stuff that you’ll see in the movies. There are parts of self that are functioning in the present, but they might be dissociated from other parts; one might go to work, another that deals with relationships, another that’s a student, and another that’s a parent. Depending on how dissociated those parts are from each other, in extreme cases, they might not even know about each other and have loss of memory for day to day events.
Derealization and depersonalization are symptoms. Depersonalization can also be considered a disorder, and in order to qualify you need to have a certain number of ongoing symptoms. The symptom of depersonalization can be quite common, as in when you don’t experience yourself as being fully in your body. When it’s a disorder, the person might walk around and feel as though their hands don’t belong to them, or their body doesn’t belong to them or that they’re a robot and so on. It’s very common with eating disorders to split off the sense of your body from yourself, where you cut off your sense of hunger, pain or satiation for example. Derealization is the experience of the external world not being real. Most type of trauma come with some aspect of derealization. Often, when something really horrific happens, the first thing we’ll say is ‘this can’t be real.’ When that experience is repeated over and over again the world feels like it’s not real. Some people might feel as if they’re not real, or that they’re martians or robots, which can be very frightening and hallucinatory in quality.
It’s interesting that you say most people will experience depersonalization and derealization at some point.
When really bad things happen, it can feel like the world isn’t real. For instance, when COVID-19 started to spread, people continuously said ‘this can’t be real.’ In a way, it’s integrated into our language. Both symptoms are really common reactions to trauma. Depersonalization becomes a disorder when it doesn’t go away, when the person walks around in that state all the time, which is really upsetting.
Can the pop cultural representations that you’ve mentioned be helpful or harmful in the attempt to continue public education?
I might disagree with some other experts, but, for example, there was a show called The United States of Tara. That was under the advice from one of the top people in the field. I found the show annoying because it’s very, very rare that you would see anything that extreme. She changes her outfits, changes her hair. These cases are usually more subtle. People who dissociate, even people with DID, don’t know they have it and their friends don’t know they have it. The shifts in state are internal, much more than external. On TV, you’ll see these extreme cases, so people think they understand what DID and dissociation are, and won’t question, perhaps, their own state.
You’ve already mentioned that symptoms of dissociation can accompany eating disorders. What other mental health issues can dissociation accompany?
Almost all mental health disorders have some aspect of dissociation. For example, there is a kind of dissociative depression, which includes being in a state where nothing feels real and you’re numb. There can be feelings that you’re living in the trauma, which can also make you feel very depressed and anxious. Really, a lot of mental health issues are related to dissociation and trauma; anxiety, depression, phobias, panic attacks, just about anything you can think of.
How do you distinguish these mild cases from more severe ones?
Severe cases are more chronic, long lasting and no longer episodic. Using language we use in the field, it becomes a trait rather than a state. Being able to get yourself out of the state is very different to when it becomes a trait that is part of your life all the time.
What does the long term treatment process look like for dissociative disorders?
There are three accepted stages of treatment. The first is stabilization, where you work to help the person become stabilized in the present as much as possible, helping them develop resources that will help them to feel grounded physically in the present. They can also start to imagine parts of themselves that will take care of the traumatised parts. You help them figure out, if they are lurching from crisis to crisis like many do and replicating patterns of chaos, how to create more stable connections. In treatment you want to be grounded for then and they should begin to internalise that. As they start to feel more safe, you might start to work with some of the trauma, but you don’t want to introduce that too early. The third stage is integration, where they’ve worked through a lot of the trauma processes and they can integrate them into their daily life, dealing with relationships and so forth.
The social world is very important through all three of these steps, especially the first and third. You want to help them build a network of support, which is part of grounding and stabilising. After they’ve worked through the trauma, they may need to repair the relationships they might have damaged and learn ways of sustaining those relationships.
Could you explain the process of ‘grounding’ further? Many resources online talk about grounding as being primarily physical. Are these methods of grounding helpful for working through dissociation?
Physical grounding focuses on attempting to counteract the depersonalization. You want the person to experience the body and you need to do that very gradually because a lot of trauma occurs in the body. When they return to the body they will re-experience the trauma, so it needs to be done very gently and very carefully (which is an endless balancing act). Grounding is about getting people to notice physical bodily sensations and orienting is about helping them to notice the here and now – to come back to the present. When a person is in a state of trauma they tend to go inwards and try to block out the world. If they are alert and watching out for danger, they can’t be in that internal state because they wouldn’t survive. One of the grounding techniques is to have the person look around the room and say what they see out loud, which should bring them into the present. There’s also breathing techniques, which can be triggering for some trauma survivors. There isn’t a magic bullet for all, each case is very different.
In the process of grounding through stable relationships, I’ve brought in support people to sessions, so that they can better understand what it is like for the person experiencing dissociation and reliving trauma. Unfortunately, in NZ (with the exception of Māori approaches which do focus on whānau), people are not trained to bring in and consult with the family, which is quite a tricky skill. There needs to be more training that focuses on working with trauma as well the support system that surrounds a patient.
What are the major issues that need to be addressed within our system so that we can better treat dissociative disorders?
ACC has created an enormous need, without, in any way, adequately supplying that need. Most ACC counsellors are burnt out and they won’t take new clients. They aren’t trained, they don’t get adequate support and they don’t get adequate supervision. There’s all of this money that’s available and there’s all of this free therapy that’s available, but they can’t find therapists who are willing to do it because they aren’t supported. It’s a burnout job, it’s very hard work. The funding is not there for the training. It’s not made a priority. There also needs to be some lessening of the bureaucracy, because part of the reason people don’t want to take ACC clients is that there’s too many reports within the current insurance system. It shouldn’t be about proving, it should just be about healing. The public system also needs to show more focus on prevention, instead of waiting for the worst case scenarios. I just don’t see where the funding is going.