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Joyce Boaz & Dr. Frank Ochberg, M.D.

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Q: Dear Dr. Ochberg, My name is Patti. I'm a Gift From Within support pal. I've never paid much attention to dissociation as it relates to trauma, until I've begun having times here lately where I zone out. My therapist confirmed that there is always some dissociation associated with trauma. I'd like to understand how it manifests itself, what type of symptoms, and also why they begin so long after the trauma. Could you discuss this?

A: Dear Patti, Dissociation is one of the least understood symptoms in psychiatry. It means an altered state of consciousness and can be very subtle, like deja vu, or quite frightening, like derealization. In deja vu, a common occurrence, a person has the sense of being in a familiar place, or having a familiar sensation, but they cannot remember the original scene. It is as though that part of the brain that gives us the sensation of similarity has been stimulated, without any good reason for the sensation to occur. In derealization, the surroundings are distorted. Objects may be larger or smaller; sounds may change volume or tone. The flaw is not in the organs of sense. Nothing wrong with the ear, the eyes or the receptors in the skin. The problem is in the brain, where perceptions are received, organized and interpreted. Derealization is episodic, not constant.

Feeling "zoned out" -entering a trance-like state- is relatively common during or after severe trauma. The term "shell shock" refers to battlefield conditions with soldiers wandering in a daze after comrades are killed and the echoes of gunfire and mortar rounds slowly subside. Dissociation can be thought of as a defense against panic and terror. Instead of having acute awareness of the surrounding danger, instead of having accurate recollection of a devastating event, one has a hypnotic reverie, like being drugged.

One of my traumatized patients experiences dissociative fugue. She drives long distances without knowing why or where. She awakens with no clear memory of the trip. But she is not psychotic. She can interact with people along the way, get gas, count change and appear to be perfectly normal. These varieties of dissociative states (deja vu, derealization, trance, fugue) do not respond well to medication and are not easy to treat with psychotherapy. Specialists in dissociation overlap with specialists in PTSD. When "zoning out" is a relatively minor component of PTSD, as it frequently is, the general principle of post-traumatic therapy apply (see ).

Any symptom of PTSD can appear long after the original trauma. Entering a trance or a fugue can be your body's way of avoiding anxiety. Coping with the cause of that anxiety is the best way to eliminate dissociation. Dissociation may feel better than anxiety, but it is not an effective way to face the world.

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