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Dissociation

Dissociation refers to an acute or chronic state in which a person stops experiencing themselves as a complete, embodied person. Their conscious experience becomes divided or interrupted, and they may lose voluntary control over particular cognitive or physical processes. People who dissociate may feel consciously detached from their sense of self, their body, their thoughts, feelings, memories and behaviours. They might have involuntary experiences that take them away from the present moment. Accounts of dissociation typically describe a “lack of integration” or descriptions of “divided consciousness” (e.g. Kennedy & Kennerley, 2013). More recent theories propose that dissociation can be classified as a state of detachment or a state of compartmentalization (Holmes et al, 2005), although both can be present at the same time. Read more
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Autonomic Nervous System

The autonomic nervous system (ANS) automatically regulates the function of body systems outside of voluntary control. The Autonomic Nervous System han ... https://www.psychologytools.com/resource/autonomic-nervous-system/

Information Handout

Before I Blame Myself And Feel Guilty

Guilt is a common post-traumatic reaction and is often the result of cognitive bias. This CBT worksheet explores common cognitive biases that have bee ... https://www.psychologytools.com/resource/before-i-blame-myself-and-feel-guilty/

Exercise

Being With Difficulty (Audio)

Being With Difficulty is a mindfulness exercise which gently brings present-moment awareness to bear upon thoughts and feelings that are more difficul ... https://www.psychologytools.com/resource/being-with-difficulty-audio/

Audio

Cognitive Behavioral Model Of Depersonalization (Hunter, Phillips, Chalder, Sierra, David, 2003)

Depersonalization is an experience where an individual feels a sense of detachment from themselves, or estrangement from their perceptions, actions, a ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-depersonalization-hunter-phillips-chalder-sierra-david-2003/

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Cognitive Behavioral Model Of Post Traumatic Stress Disorder (PTSD: Ehlers & Clark, 2000)

Anke Ehlers’ & David Clark’s Cognitive Behavioral Model Of Post-Traumatic Stress Disorder (PTSD) is an influential account of the co ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-post-traumatic-stress-disorder-ptsd-ehlers-clark-2000/

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Critical Care And PTSD

The Critical Care And PTSD information handout is designed to help clients to learn about the properties of critical care that can increase the likeli ... https://www.psychologytools.com/resource/critical-care-and-ptsd/

Information Handout

Critical Illness Intensive Care And Post-Traumatic Stress Disorder (PTSD)

This is a free guide designed for people who have spent time in an intensive care unit and are experiencing symptoms of post-traumatic stress disorder ... https://www.psychologytools.com/resource/critical-illness-intensive-care-and-post-traumatic-stress-disorder-ptsd/

Free Guide

Dissociation – Self-Monitoring Record

Developing self-monitoring skills teaches clients to systematically observe and record specific targets such as their own thoughts, body feelings, emo ... https://www.psychologytools.com/resource/dissociation-self-monitoring-record/

Worksheet

Fight Or Flight Response

The fight or flight response is an automatic physiological reaction to an event that is perceived as stressful or frightening. The perception of threa ... https://www.psychologytools.com/resource/fight-or-flight-response/

Information Handout

Grounding Objects (Audio)

The Grounding Objects exercise is a simple technique which teaches people with PTSD or dissociative disorders how to use objects with particular senso ... https://www.psychologytools.com/resource/grounding-objects-audio/

Audio

Grounding Statements (Audio)

Grounding techniques are used to help people to reorient themselves to the present moment and to safety. Grounding Statements are a form of cognitive ... https://www.psychologytools.com/resource/grounding-statements-audio/

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Grounding Techniques

Individuals who have experienced trama often find it difficult to stay within the ‘window of tolerance’. Grounding techniques (which can b ... https://www.psychologytools.com/resource/grounding-techniques/

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Grounding Techniques Menu

Dissociation can be described as a shift of a person’s attention away from the present moment. When working with traumatized clients, this shift oft ... https://www.psychologytools.com/resource/grounding-techniques-menu/

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Hotspot Record

Enhanced ‘reliving’ in trauma-focused CBT for PTSD involves addressing the meaning associated with ‘hot spots’ of traumatic me ... https://www.psychologytools.com/resource/hotspot-record/

Worksheet

How Trauma Can Affect You (CYP)

Trauma can result in a wide variety of symptoms, experiences, and behaviors. As well as post-traumatic stress disorder (PTSD), prevalence rates of oth ... https://www.psychologytools.com/resource/how-trauma-can-affect-you-cyp/

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How Your Body Responds To Stress

Many clients identify with the concept of ‘stress’ more readily than ‘threat’ and the The How Your Body Responds To Stress information handou ... https://www.psychologytools.com/resource/how-your-body-responds-to-stress/

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Intrusion Record

What differentiates intrusive congitions in OCD is the meaning that clients with OCD attach to them. The Intrusion Record is a CBT worksheet for captu ... https://www.psychologytools.com/resource/intrusion-record/

Worksheet

Intrusive Memory Record

Intrusive (unwanted, involuntary) memories are a common feature of PTSD, but also depression and other conditions. This Intrusive Memory Record is des ... https://www.psychologytools.com/resource/intrusive-memory-record/

Worksheet

Narrative Exposure Therapy (NET)

Narrative Exposure Therapy (NET) is an empirically validated treatment for survivors of multiple traumatic events who are suffering from post-traumati ... https://www.psychologytools.com/resource/narrative-exposure-therapy-net/

Free Guide

Nightmare Exposure And Rescripting

Imagery rescripting is an effective treatment for intrusive and unwanted memories. Nightmare Exposure And Rescripting employs similar techniques and c ... https://www.psychologytools.com/resource/nightmare-exposure-and-rescripting/

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Progressive Muscle Relaxation

Progressive relaxation training originated in the 1930’s as a treatment for tension and anxiety. Edmund Jacobsen developed a systematic and lengthy ... https://www.psychologytools.com/resource/progressive-muscle-relaxation/

Exercise

Progressive Muscle Relaxation (Audio)

The Progressive Muscle Relaxation exercise guides the listener through a sequence in which muscle groups are tensed and relaxed. ... https://www.psychologytools.com/resource/progressive-muscle-relaxation-audio/

Audio

Progressive Muscle Relaxation (Edition 1)

Muscle tension is one reaction to stress and anxiety. This exercise includes instructions for Progressive Muscle Relaxation, a technique for promoting ... https://www.psychologytools.com/resource/progressive-muscle-relaxation-edition-1/

Exercise

Properties Of Trauma Memories

Important properties of trauma memories include involuntary recall, ‘nowness’, vividness, and immutability. People who have experienced t ... https://www.psychologytools.com/resource/properties-of-trauma-memories/

Information Handout

Psychology Tools For Mindfulness Audio Collection

The Psychology Tools For Mindfulness Audio Collection is the perfect way to introduce your clients to the practice of mindfulness. Developed by a clin ... https://www.psychologytools.com/resource/psychology-tools-for-mindfulness-audio-collection/

Audio Collection

Psychology Tools For Overcoming PTSD Audio Collection

The Psychology Tools for Overcoming PTSD Audio Collection is designed for anyone with post-traumatic stress disorder (PTSD). This skills development p ... https://www.psychologytools.com/resource/psychology-tools-for-overcoming-ptsd-audio-collection/

Audio Collection

Psychology Tools For Relaxation Audio Collection

The Psychology Tools For Relaxation Audio Collection is designed to help anyone experiencing stress or heightened physiological arousal. The audio col ... https://www.psychologytools.com/resource/psychology-tools-for-relaxation-audio-collection/

Audio Collection

PTSD And Memory

Alterations in the way the brain processes ‘normal’ vs. ‘traumatic’ material are thought to be responsible for the intrusive n ... https://www.psychologytools.com/resource/ptsd-and-memory/

Information Handout

PTSD Film Projection Metaphor

Treatment for trauma often involves exposure to traumatic thoughts and memories, and many clients are understandably reluctant to attempt this. The PT ... https://www.psychologytools.com/resource/ptsd-film-projection-metaphor/

Information Handout

PTSD Formulation

This PTSD Formulation is designed for use in trauma-focused cognitive therapy for PTSD (CT-PTSD): an empirically supported treatment for Post-Traumati ... https://www.psychologytools.com/resource/ptsd-formulation/

Worksheet

PTSD Linen Cupboard Metaphor

Treatment for trauma often involves exposure to traumatic thoughts and memories, and many clients are understandably reluctant to attempt this. The PT ... https://www.psychologytools.com/resource/ptsd-linen-cupboard-metaphor/

Information Handout

Reactions To Trauma

Traumatic events are shocking and it is normal to feel overwhelmed. Not everybody reacts in the same way though and there is no ‘right’ way to res ... https://www.psychologytools.com/resource/reactions-to-trauma/

Information Handout

Recognizing Depersonalization / Derealization Disorder (DPD)

Depersonalization / Derealization Disorder (DPD) is characterised by experiences of unreality and detachment from oneself and the world. People suffer ... https://www.psychologytools.com/resource/recognizing-depersonalization-derealization-disorder-dpd/

Information Handout

Recognizing Post Traumatic Stress Disorder (PTSD)

Post-Traumatic Stress Disorder (PTSD) follows an experience of trauma and is characterized by recurrent involuntary memories or other re-experiencing ... https://www.psychologytools.com/resource/recognizing-post-traumatic-stress-disorder-ptsd/

Information Handout

Relaxed Breathing

Practising Relaxed Breathing serves to reduce physiological arousal and can be an excellent grounding technique. This client information handout descr ... https://www.psychologytools.com/resource/relaxed-breathing/

Exercise

Relaxed Breathing Record Form

Practising relaxed breathing serves to reduce physiological arousal and can be an excellent grounding technique. This record form helps clients to mon ... https://www.psychologytools.com/resource/relaxed-breathing-record-form/

Worksheet

Responses To Threat: Freeze, Appease, Flight, Fight

Human beings are programmed to respond automatically in a variety of ways to a threat including freezing, escaping, and dissociation. Traumatized indi ... https://www.psychologytools.com/resource/responses-to-threat-freeze-appease-flight-fight/

Information Handout

Sensory Grounding Using Smells (Audio)

The Sensory Grounding Using Smells exercise is an audio track from the Psychology Tools For Overcoming PTSD Audio Collection. It is designed to teach ... https://www.psychologytools.com/resource/sensory-grounding-using-smells-audio/

Audio

Sensory Grounding Using Your Five Senses (Audio)

The Sensory Grounding Using Your Five Senses exercise is an audio track from the Psychology Tools For Overcoming PTSD Audio Collection. It is designed ... https://www.psychologytools.com/resource/sensory-grounding-using-your-five-senses-audio/

Audio

Stimulus Discrimination

Stimulus discrimination is a component of cognitive behavioral treatment for post-traumatic stress disorder (PTSD). Clients are guided to deliberately ... https://www.psychologytools.com/resource/stimulus-discrimination/

Exercise

Stimulus Discrimination (Audio)

Stimulus Discrimination is designed to help people with post-traumatic stress disorder (PTSD) to ‘retrain their brain’ in order to attend automat ... https://www.psychologytools.com/resource/stimulus-discrimination-audio/

Audio

Symptom Tracker

Self-monitoring of thoughts, feelings, and symptoms is an essential skill in cognitive behavioral therapy (CBT). This generic symptom tracker helps cl ... https://www.psychologytools.com/resource/symptom-tracker/

Worksheet

Trauma, Dissociation, And Grounding

Trauma, Dissociation, and Grounding is a guide written for clients who have experienced trauma and who are troubled by dissociation. It provides clear ... https://www.psychologytools.com/resource/trauma-dissociation-and-grounding/

Guide

Types Of Dissociation

The Types Of Dissociation information handout is designed for clients who have experienced trauma and describes dissociation using accessible terminol ... https://www.psychologytools.com/resource/types-of-dissociation/

Information Handout

Understanding Depersonalization And Derealization

Our ‘Understanding…’ series is a collection of psychoeducation guides for common mental health conditions. Friendly and explanatory, they are co ... https://www.psychologytools.com/resource/understanding-depersonalization-and-derealization/

Guide

Understanding Post-Traumatic Stress Disorder (PTSD)

Our ‘Understanding…’ series is a collection of psychoeducation guides for common mental health conditions. Friendly and explanatory, they are co ... https://www.psychologytools.com/resource/understanding-post-traumatic-stress-disorder-ptsd/

Guide

Your Stone Age Brain

Your Stone Age Brain is an information handout which describes the freeze-flight-fight response: a set of evolutionary adaptations that increase the c ... https://www.psychologytools.com/resource/your-stone-age-brain/

Information Handout

Your Stone Age Brain (CYP)

Your Stone Age Brain is an information handout designed to stimulate discussion with anxious children & adolescents. It describes the freeze-fligh ... https://www.psychologytools.com/resource/your-stone-age-brain-cyp/

Information Handout

Assessment

  • Brief Dissociative Experiences Scale (DES-B) | Dalenberg, Carlson | 2010
    • Scale  download  archived copy
    • DES-B (Dalenberg C, Carlson E, 2010) modified for DSM-5 by C. Dalenberg and E. Carlson.
  • Dissociative Experiences Scale – II | Carlson, Putnam |1993
    • Scale  download  archived copy
    • Carlson, E.B. & Putnam, F.W. (1993). An update on the Dissociative Experience Scale. Dissociation 6(1), p. 16-27.
  • Shutdown Dissociation Scale (Shut-D) | Schauer, Schalinski, Elbert | 2015

Information Handouts

What is dissociation?

When functioning normally, our conscious experience is supported by a number of integrated processes: sensations and perceptions, sense of self, memories, feelings and actions. Dissociation refers to an experience or feeling of disconnection that disrupts this integrated experience: “a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment” (APA, 2013). Dissociation is often key in the presentation of individuals who have undergone significant trauma (Steele & van der Hart, 2013).

Signs and symptoms of dissociation

It is possible to place acute episodes of dissociation on a continuum from benign and possibly pleasant experiences to those that are distressing and pathological (Carlson & Putnam, 1993; Kennedy & Kennerley, 2013).

Benign examples of dissociation include:

  • Daydreaming.
  • Going on ‘automatic pilot’ whilst walking or driving.
  • Becoming completely absorbed in an activity, e.g. when reading or watching a film.
  • Going ‘blank’ mentally.

Clinically-relevant examples of dissociation include:

  • Being unable to remember recent or past events (amnesia).
  • Depersonalisation (feeling detached from oneself) .
  • Derealisation (feeling detached from the world).
  • Being unable to perform actions or skills that are normally under voluntary control.
  • Identity confusion (feeling that your self is incoherent and not continuous over time).
  • Intrusive traumatic memories (flashbacks).

The many clinical manifestations of dissociation have a number of common features. Dissociation is often accompanied by somatic symptoms that can affect movement, perception, sensation and appetite. Individuals also often have a history of childhood abuse and neglect. Dissociation features prominently in a range of clinical conditions:

What causes dissociation?

Researchers have linked experiences of detachment to specific neuro-biological states (e.g. Nijenhuis & den Boer, 2010; Schauer & Elbert, 2010). There is agreement that dissociation can be a protective mechanism that helps individuals to survive overwhelming situations, emotions or memories. Under threatening conditions it may be helpful to be in a state of vigilance, but to emotional and physical inhibition which prevents you from doing something that might endanger you further, such as provoking an attacker, or which may help to reduce pain or suffering when injury is unavoidable (Schauer & Elbert, 2010). Whilst this state is thought to help people to survive a threatening situation, it can impair the formation of autobiographical memories and lead to poorly integrated, intrusive and distressing trauma memories (Kennedy & Kennerley, 2013).

Cognitive theories support the idea that detachment – being taken away from the here and now – is protective, as it means that all the information and emotions do not have to be attended to and processed (Kennedy & Kennerley, 2013). In clinical conditions episodes of dissociation typically occur when emotions become overwhelming, acting as an emotional pressure relief valve that helps the person to cope. Dissociation itself can be aversive thought, and maladaptive behaviours can be negatively conditioned through a link with dissociation. These include self-harm, bingeing, starving oneself or drug use. They might be performed to escape an overwhelming emotion (i.e. to induce dissociation), or to come out of a ‘numbness’ (i.e. to return from dissociation; Kennerley & Kishcka, 2013).

Psychological Models And Theory Of Dissociation

Recognisable descriptions of dissociative episodes are found in 17th and 18th Century documents, with the first analytical accounts of ‘disintegrated’ or split consciousness appearing in the 1800s (Kennedy & Kennerley, 2013). Pierre Janet was the first to document traumatic flashbacks and the way in which personality states could switch dramatically with their onset (ibid). Breuer and Freud (1893) made a direct link between traumatic events, traumatic memories and ‘hysterical’ (dissociative) phenomena.

“The memories which have become the determinants of hysterical phenomena persist for a long time with astonishing freshness and with the whole of their affective colouring… these memories, unlike other memories of their past lives, are not at the patients’ disposal. On the contrary, these experiences are completely absent from the patients’ memory when they are in a normal psychical state”

More recent theories have tried to categorize different kinds of dissociation, or split a continuum of dissociation into pathologies or conditions with ‘greater’ degrees of dissociation (e.g. dissociative personality disorder) as compared to more quotidian experiences people may have (being absorbed in a book, day dreaming, driving without being fully aware; ibid). Some have argued that everyday experiences such as day-dreaming and absorption should not be classed as true dissociation. Current theory suggests that there is continuum of dissociation that can become pathological at the extreme end and that “any specific presentation of dissociation can be experienced along a continuum of severity” (Kennedy & Kennerley, 2013).

Holmes and colleagues (2005) proposed a distinction between two kinds of dissociative experience: detachment and compartmentalization:

“Detachment constitutes a mental state with a core neurophysiological profile, unlike compartmentalization, which can exist in many forms… compartmentalization refers to a lack of integration of information within the cognitive system, while detachment refers to an experienced state of disconnection from the self or environment.”

  • Detachment describe experiences where the person feels separated or disconnected. Examples include depersonalisation, derealisation, and out of body experiences. The individual has an experience of being separated from their body, the world, or themselves. It may include emotional numbing. Detachment includes peri-traumatic dissociation and the intrusive flashbacks experienced by those with PTSD. This is because flashbacks are likely caused by poorly processed autobiographical memories due to dissociation (detachment) at the time of the trauma and flashbacks often include an experience or sense of detachment.
  • Compartmentalization describes the inability to control cognitive, motor or somatic processes that would normally be under voluntary control. Examples include dissociative amnesia, and symptoms seen in functional / conversion disorders such as gait problems or paralysis, deafness, voice loss, and sight loss. During compartmentalization, cognitive or bodily processes become inaccessible despite the fact that they continue to operate normally (e.g. no physical or physiological impairment is found) and the processes continue to influence cognition, emotions and behaviour.

Kennerley (2009) conceptualizes different manifestations of dissociation as ‘Tuning In’ or ‘Tuning Out’.

  • Tuning In refers to an intense experience or state. Benign experiences would be day-dreaming, or being fully absorbed in some activity. This is in contrast to a distressing flashback memory that cannot easily be stopped.
  • Tuning Out refers to “distancing or suppressing an experience”. A state of detachment that can be broad, as in depersonalisation and derealisation, or specific as for amnesia or emotional numbing.

Kennerley’s description is aligned with the model by Holmes et al (2005) where Tuning Out links to detachment, and different aspects of compartmentalization can be described as Tuning Out (e.g. amnesia, emotional numbing), and Tuning In (e.g. traumatic flashbacks). It is important to note that both can occur simultaneously – for example, during a traumatic flashback memory an individual is tuned in to the memory whilst being detached or tuned out of their immediate environment.

Neurobiological models of dissociation

Dissociative detachment has been linked to a specific, protective neurobiological state. During an extreme or threatening situation, Schauer & Elbert (2010) proposed that the sympathetic nervous system ramps up in preparation for action, with adrenalin release leading to physiological responses such as heart rate increase and an increase in muscle tension. If a threat is inescapable the mind and body may move through a ‘fright’ response that includes hyper-alertness, fear and immobility, and then dissociative ‘shut-down’ responses of flagging (emotional numbing, surrender) and fainting.

Nijenhuis & den Boer (2010) hypothesize that individuals with PTSD have a dissociated personality, with an ‘emotional’ personality (EP) that is constantly vigilant and focused on threats, and an ‘apparently normal’ personality (ANP) that is detached from the trauma and focused on day to day tasks and living. These different aspects of the personality are structurally dissociated and underpinned by different psychobiological systems. The EP is sensitive to trauma cues and triggers, and relies on limbic structures such as the amygdala, insula with low activation of hippocampal and frontal regions. The ANP system is characterised by avoidance of triggers and threats, and may be linked to somatosensory association areas in the cortex.

For individuals who experience depersonalisation and derealisation, one neurobiological model proposes that they are predisposed towards an inhibited affective response during stressful situations (Sierra & Berrios, 1998). Here, there is an upregulation of pre-frontal regions and a parallel inhibition of limbic structures and their associated emotional responses. This produces a state of high vigilance (the pre-frontal systems ‘watching’) but a detachment from emotional states that underpins the feeling of disconnection from oneself or one’s embodied experience.

Evidence-Based Psychological Approaches For Working With Dissociation

  • Strategies for returning attention to the here and now
    Clients can be trained to manage dissociative episodes with techniques such as grounding and cognitive restructuring (Kennerley, 1996).
  • Trauma-focused techniques for working with intrusive memories
    ‘Processing’ memories of trauma with exposure based treatments can help to reduce the extent to which clients dissociate. Similarly, approaches which help clients to alter or construct new meanings can help to reduce dissociate symptoms associated with trauma memories.
  • Cognitive approaches for working with appraisals of dissociation
    Threatening appraisals of dissociation (e.g. “I’m losing my mind”) can also be associated with significant distress. Cognitive approaches to depersonalisation and derealization (e.g. Hunter et al, 2003) work to explore client appraisals of dissociation, and Černis et al (2022) suggest that a similar approach may be helpful for people experiencing dissociation in the context of psychosis.

References

  • American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders: DSM-5. 5th edn. Washington, D.C.: American Psychiatric Publishing.
  • Breuer, J. and Freud, S. (1893). On The Psychical Mechanism of Hysterical Phenomena. The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume II (1893-1895): Studies on Hysteria, 1-17
  • Carlson, E. B., & Putnam, F. W. (1993). An update on the dissociative experiences scale. Dissociation: progress in the dissociative disorders. 6(1), 16–27.
  • Černis, E., Ehlers, A., & Freeman, D. (2022). Psychological mechanisms connected to dissociation: Generating hypotheses using network analyses. Journal of Psychiatric Research.
  • Holmes, E. A., Brown, R. J., Mansell, W., Fearon, R. P., Hunter, E. C., Frasquilho, F., & Oakley, D. A. (2005). Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical Psychology Review, 25(1), 1-23.
  • Hunter, E. C. M., Phillips, M. L., Chalder, T., Sierra, M., & David, A. S. (2003). Depersonalisation disorder: a cognitive–behavioural conceptualisation. Behaviour Research and Therapy, 41(12), 1451-1467.
  • Kennedy, F.C. & Kennerley, H. (2013) The development of our understanding of dissociation. Ch.13 in F.C. Kennedy, H. Kennerley & D.G. Pearson (Eds.). (2013). Cognitive behavioural approaches to the understanding and treatment of dissociation. London: Routledge.
  • Kennerley, H. (2009) Cognitive therapy for post-traumatic dissociation. Ch. 7 in N. Grey (Ed). A casebook of cognitive therapy for traumatic stress reactions. London, UK: Routledge.
  • Kennerley, H. & Kischka, U. (2013) The brain, neuropsychology and dissociation. Ch. 5 in F.C. Kennedy, H. Kennerley & D.G. Pearson (Eds.). (2013). Cognitive behavioural approaches to the understanding and treatment of dissociation. London: Routledge.
  • Nijenhuis, E. R., & den Boer, J. A. (2010). Psychobiology of Traumatization and Trauma-Related Structural Dissociation of the Personality. Ch.21, p.337-365, in P.F.Dell & J.A. O’Neil (Eds) Dissociation and the Dissociative Disorders: DSM-V and Beyond,. Routledge, Taylor & Francis, Abingdon, UK.
  • Schauer, M., & Elbert, T. (2010). Dissociation following traumatic stress. Journal of Psychology, 218, 109-127.
  • Sierra, M. & Berrios, G. E. (2000) The Cambridge Depersonalisation Scale: a new instrument for the measurement of depersonalisation. Psychiatry Research, 93, 153–164.
  • Steele, K., & van der Hart, O. (2013). Understanding attachment, trauma and dissociation in complex developmental trauma disorders. In Attachment Theory in Adult Mental Health. Routledge.