Detachment Predicts Worse Posttraumatic Outcomes

Pauline Anderson

September 08, 2022

Feelings of detachment following a traumatic event are a marker of more severe psychiatric outcomes, including depression and anxiety, new research suggests.

The results highlight the importance of screening for dissociation in patients who have experienced trauma, study investigator Lauren A.M. Lebois, PhD, director of the Dissociative Disorders and Trauma Research Program at  McLean Hospital in Belmont, Massachusetts, told Medscape Medical News.

"Clinicians could identify individuals potentially at risk of a chronic, more severe psychiatric course before these people go down that road, and they have the opportunity to connect folks with a phased trauma treatment approach to speed their recovery," said Lebois, who is also an assistant professor of psychiatry at Harvard Medical School.

The study was published in the September issue of the American Journal of Psychiatry.


Feelings of detachment or derealization are a type of dissociation. Patients with the syndrome report feeling foggy or as if they are in a dream. Dissociative diagnoses are not rare and, in fact, are more prevalent than schizophrenia.

Research supports a powerful relationship between dissociation and traumatic experiences. However, dissociation is among the most stigmatized of psychiatric conditions. Even among clinicians and researchers, beliefs about dissociation are often not based on the scientific literature, said Lebois.

"For instance, skepticism, misunderstanding, and lack of professional education about dissociation all contribute to striking rates of underdiagnosis and misdiagnoses," she said.

Lebois and colleagues used data from the larger Advancing Understanding of Recovery After Trauma (AURORA) study and included 1464 adults, mean age 35 years, appearing at 22 US emergency departments. Patients experienced a traumatic event such as a motor vehicle accident or physical or sexual assault.

About 2 weeks after the trauma, participants reported symptoms of derealization as measured by a two-item version of the Brief Dissociative Experiences Scale.

Brain Imaging Data

A subset of 145 patients underwent functional MRI, during which they completed an emotion reactivity task (viewing fearful-looking human faces) and a resting-state scan.

In addition to measuring history of childhood maltreatment, researchers assessed posttraumatic stress symptom severity at 2 weeks and again at 3 months using the posttraumatic stress disorder (PTSD) Checklist. Also at 3 months, they measured depression and anxiety symptoms, pain, and functional impairment.

About 55% of self-report participants and 50% of MRI participants endorsed some level of persistent derealization at 2 weeks.

After controlling for potential confounders, including sex, age, childhood maltreatment, and current posttraumatic stress symptoms, researchers found persistent derealization was associated with increased ventromedial prefrontal cortex (vmPFC) activity while viewing fearful faces.

The vmPFC helps to regulate emotional and physical reactions. "This region puts the 'brakes' on your emotional and physical reactivity — helping you to calm down" after a threatening or stressful experience has passed, said Lebois.

Researchers also found an association between higher self-reported derealization and decreased resting-state connectivity between the vmPFC and the orbitofrontal cortex (OFC) and right lobule VIIIa — a region of the cerebellum involved in sensorimotor function.

"This may contribute to perceptual and affective distortions experienced during derealization — for example, feelings that surroundings are fading away, unreal, or strange," said Lebois.

More Pain, Depression, Anxiety

Higher levels of self-reported derealization at 2 weeks posttrauma predicted higher levels of PTSD, anxiety, and depression as well as more bodily pain and impairment in work, family, and social life at 3 months.

"When we accounted for baseline levels of posttraumatic stress symptoms and trauma history, higher levels of self-reported derealization still predicted higher posttraumatic stress disorder and depression symptoms at 3 months," said Lebois.

Additional adjusted analyses showed increased vmPFC activity during the fearful face task predicted 3-month self-reported PTSD symptoms.

Lebois "highly recommends" clinicians screen for dissociative symptoms, including derealization, in patients with trauma. Self-report screening tools are freely available online.

She noted patients with significant dissociative symptoms often do better with a "phase-oriented" approach to trauma treatment.

"In phase one, they learn emotional regulation skills to help them take more control over when they dissociate. Then they can successfully move on to trauma processing in phase two, which can involve exposure to trauma details."

Although the field is not yet ready to use brain scans to diagnose dissociative symptoms, the new results "take us one step closer to being able to use objective neuroimaging biomarkers of derealization to augment subjective self-report measures," said Lebois.

A limitation of the study was it could not determine a causal relationship, as some derealization may have been present before the traumatic event. The findings may not generalize to other types of dissociation, and the derealization assessment was measured only through a self-report 2 weeks after the trauma.

Another limitation was exclusion of patients with self-inflicted injuries or who were involved in domestic violence. The researchers noted the prevalence of derealization might have been even higher if such individuals were included.

An Important Investigation

In an accompanying editorial, Lisa M. Shin, PhD, Department of Psychology, Tufts University, and Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, notes having both clinical and neuroimaging variables as well as a large sample size makes the study "an important investigation" into predictors of psychiatric symptoms post-trauma.

Investigating a specific subtype of dissociation — persistent derealization — adds to the "novelty" of the study, she said.

The new findings "are certainly exciting for their potential clinical relevance and contributions to neurocircuitry models of PTSD," she writes.

Some may argue administering a short, self-report measure of derealization "is far more efficient, cost-effective, and inclusive than conducting a specialized and expensive fMRI scan that is unlikely to be available to everyone," notes Shin.

However, she added, a potential benefit of such a scan is identification of specific brain regions as potential targets for intervention. "For example, the results of this and other studies suggest that the vmPFC is a reasonable target for transcranial magnetic stimulation (TMS) or its variants."

The new results need to be replicated in a large, independent sample, said Shin. She added it would be helpful to know if other types of dissociation, and activation in other sub-regions of the vmPFC, also predict psychiatric outcomes after a trauma.

The study was supported by NIMH grants, the US Army Medical Research and Material Command, One Mind, and the Mayday Fund. Lebois has received grant support from NIMH, and her spouse receives payments from Vanderbilt University for technology licensed to Acadia Pharmaceuticals. Shin receives textbook-related royalties from Pearson.

Am J Psychiatry .  Published September 2022 issue. Full text, Editorial

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