From Post-Traumatic Stress Disorder to: Present Traumatic GROWTH

While Carol is known throughout the world as a #1 Leadership Coach, Founder of the Institute of Coaching, Assistant Professor at Harvard Medical School, what is not known is she was a specialist in treating survivors of multiple trauma before shifting to peak performance and leadership coaching. Here she shares information and wisdom from those 15 years or work.

Nearly all of us have heard of PTSD, Post Traumatic Stress Disorder.

Did you know 2/3 of those experiencing trauma report feeling stronger as a result?

This is called Post Traumatic Growth and there are many ways to find:

THE PATH TO “G”

We can be forged into stronger versions of ourselves and develop backbones of steel.

The term PTSD is being thrown around in ways that are not helpful; and make normal responses to overwhelming life events sound like clinical conditions. In addition, it can make some fearful they will get it later. There is a difference between being traumatized and being impacted by an event.

Let’s not be Pollyanna about this. COVID 19 is a teeth-gritting experience. The phases go something like what I describe below. Each phase has its unique challenges; and each requires a different kind of growth from us. Each phase can make us stronger. As we work to finding the path to “G.”

Phases

Climbing the mountain: Many are past the first phase of shock, fear, quick, riptide speed of change. This is not true if you or a loved one has just been diagnosed with COVID. If you are on the front lines, you can revisit this phase part of every day.

The long plateau of endurance: Phase two is more the “chronic” experience. Chronic does not mean never recover, it means we do not know when we will recover. It requires patience and pacing ourselves. (See Resilience Under Fire).

Slogging through the swamp: Phase three is utterly uninteresting, lethargy competes with irritation and boredom as the flavor of the day. At some moment we will hit our “saturation point” and snap or crash. Give yourself time, and compassion. Try not to withdraw or attack to manage it. Your endurance will be tested.

Out of the muck: Phase four requires a surge of strength. If you’ve even been caught in a bog (I have) it is stunning how hard it is to pull out. You need a calm head. Often you need help. You think you’re back on dry land. Then it’s more swamp.

Back on dry land: Phase five is actually very dangerous. Shifting out of the COIVD lifestyle is going to be unpredictable. In lockdown you don’t have a lot of choice – when things are safe choices are easy. Now it’s decision time, Again and again. Now you have to dig into your truth, your gut feelings and be highly aware of reacting impulsively.

Unknown landscape: Phase six is simply unknown. What we do know is we will somehow navigate it together. It may not be pretty, but we will get through.

What is PTSD and what’s wrong with applying it to what we are going through now?

Post-Traumatic Stress “Disorder” develops in some people who have experienced a shocking, scary or dangerous event. It is particularly challenging when this event is intense or prolonged. “Disorder” is when the reaction is severe, unremitting, and is no longer related to events in the current or recent past.

Why isn’t PTSD an appropriate label for what we are going through? You may feel at wits end, that you can’t take it anymore and either stop reacting or over-react to small things?  

Post:          But this is Present

Traumatic:     Trauma is an overwhelming life event, Traumatic is different

Stress:        Is physiological coping to activate us in danger

Disorder:      Distress, even intense distress in trying circumstances is not a disorder

P = Post                  But this is present, not past.

T = Traumatic             Trauma is an overwhelming life event, this is overwhelming.

Traumatic is when your own options for coping are not sufficient. When these last more than a month after the experience is over, and you continuously recycle through the experience of the event, we can consider this a more serious level of traumatic.

S = Stress                Physical and psychological reactions to get us out of danger.

When your brain detects danger, it goes into action mode. Adrenaline and cortisone shoot up, neurotransmitters signal emotions such as anger or fear. Your palms sweat to increase your grip; your reaction time gets faster as your blood pumps harder to get more oxygen. Stress is your friend when you need it. Breathing, pacing yourself, mindfulness, all these interventions “trick” your brain into thinking you are out of harm’s way.

D = Disorder              Distress, not Disorder and it is understandable.

As above, it’s “disorder” only when the reaction stays strong or gets even more intense after the danger is over.

What’s the Difference?

Factors that lead to PTSD intensity + duration + vulnerability

Factors that overcome it: Compassion, Connection, Meaning & Purpose

Trauma or Overwhelming Life Distress is not Traumatic Stress Disorder

Here are some differences

Traumatic Distress	Symptoms or Signs of Traumatic Disorder
During the overwhelming time	Lasting days or weeks or more after overwhelming event
Feeling overwhelmed	Flashbacks where the past eclipses the present
Future feels fluid or vague	Flashbacks where the past eclipses the present
Hitting the wall	Fragmented, unable to think for over a day
Flashes of intense emotion	Triggered in high emotion the majority of the time for days
Compartmentalizing	Dissociation, number, fuzzy and don’t even know it
Difficulties sleeping	Can’t sleep, nightmares
Repeating Worry	Intrusive thoughts you can’t escape.
Hitting the saturation point	Complete Shutdown.
Burnout	Collapse, Cynicism, Helpless, Complete Shutdown
Irritability or emotions blocked	Rages and emotional volatility or Numb

Those working under extended high stress can experience burnout;

Burnout:

• Emotional, mental or physical exhaustion, just can’t cope
• Cynicism, depression and lethargy, feeling jaded or shut down
• IF it’s tied to one specific event it’s stress, not burnout
• IF it’s tied to overwhelming amount of work, it’s exhaustion, and physical

What helps?

• Have a sense of purpose and meaning in what you are doing.
• Have a positive impact on others.
• Have pieces of your life where you CAN do something.
• Identify where you are just stretched too far and need a temporary collapse somewhere comfortable.
• Pull yourself together for a while and allow another to collapse while you take up the lead.

THE PATH TO “G”

We can be forged into stronger versions of ourselves and develop backbones of steel.

Post-traumatic growth (PTG) is the positive change you can experience as a result of struggling with major life crises or a traumatic event. It makes you question your core beliefs and challenge your capabilities to finally grow and creates stronger character.  

You can lean into what you can learn about yourself and others at this time. Notice what really matters to you and have a deeper sense of purpose – what you can do for others.

What does traumatic growth look like?

In my years working with survivors there were clear signs that someone had grown.

What are the signs you have recovered from trauma? These are signposts.

1. Relationship with self
2. Relationship with others
3. Increased sense of Meaning for your life
4. Increase sense of Purpose on how to help others

Relationship with yourself

The key is moving toward self compassion. When you are overwhelmed to remember this is an understandable reaction. Bad experiences do not have to define you. Can you relate to yourself as you would a good friend or a child?

Relationship with your emotion:

Growth is being caring with yourself about what you are feeling. It is having the emotion with you, in the passenger seat of the car, not the driver’s seat. You may find yourself able to feel compassion for others in a much more powerful way as you see the suffering and courage of people during COVID.

Managing trauma induced emotion. There tend to be two patterns of responses to overwhelming life events. We can swing back and forth. In the trauma literature we describe those who numb their emotion and those who are flooded.

When you are flooded or triggered, the goal is to downshift and ride the emotion like a wave vs. thrashing and getting caught in the surf. Acceptance Commitment Training, where you can say to yourself: I am feeling overwhelmed at this moment, sounds too simple to be helpful. But it is You, having the feeling, not the feeling having you.

It can also be useful to ask yourself to try to lower the volume on the feeling and helping to stabilize by breathing, reading, listening to music or talking to someone. Do not judge if someone is flooded. Find the balance between just being with them and helping them downshift. “You’ll be okay,” can be soothing or feel like an invalidation of the experience. The goal is to be as centered as possible. (See Resilience Under Fire, below for more information.)

When you are numbed the answer is NOT to get the other person to feel their feelings. What is important is to know that feeling “nothing” isn’t that you don’t care. It means you have hit your own saturation point, and this is how you “feel” overwhelmed. The interventions are the same as flooding, you want to get to a place of feeling centered and as safe as possible. Don’t judge yourself and don’t judge others who appear not to care because they don’t look upset.

If you are grieving, remember it is a journey. It will take time. Try to take in what was good about the person you have lost and make them eternal in your heart. There is no easy way through it and time feels irrelevant right now. Walk through the stages of grief at the pace that is right for you, not what you think should be right for you and not what others feel is the right pace for you.

Emotional contagion: Some of us “catch” the emotions of others and it can be hard to know where your feelings/experience ends and the other persons begins. It’s not just “I feel that too.” It’s, this is my version of how I feel about that, is that like yours? Some of us catch sadness or depression, others of us don’t. Then some of us catch anger, or anxiety. Notice which emotions in others activate you and work on grounding yourself and not leaping toward or away from that person.

Relationship with others:

Extreme circumstances can make us exaggerated versions of ourselves regarding how we are relating to others. As with emotions, we can overplay or underplay the way our experience shapes how we connect.

Growth is an expanded heart and the capacity to pull out of ourselves and notice what others need (not overlooking yourself). Ask yourself – what does this person need from me right now?

It could be...nothing...or caring...or space.

The golden rule is wrong. Don’t treat others as you would like to be treated. Treat them as they would like to be treated, which may be the opposite of what you need or would want.

Notice if you are tending to withdraw from people and ask yourself if this is what you truly want. Learn from what you’ve done in the past. Lean in and ask for connection or help more than you might otherwise. If your only connections are virtual, really take in the other as much as you can. When connecting virtually, your voice tone counts a lot, it can convey the warmth and caring you wish you could in person.

Ask yourself, if it’s the other way, if you need to slow down and breathe before you ask for help or talk. Wait just a minute and see.

Relationship to Meaning

How do you make sense of what is happening? Is it all just a random set of dots or can you connect them and see the bigger picture?

Post Traumatic Growth is about making meaning and finding your learning path forward. It isn’t about feeling good or confident. If you want to roll your eyes at “what can you learn from this?” you may not be helping yourself grow. I am not talking about being addicted to the silver lining. Silver linings only exist with clouds, and we can’t deny things.

Deeper Purpose:

Crucibles: In chemistry it is when two elements are heated up so strongly that they transform into something else. With people, as your situation heats up, how can you also transform? Can you keep asking yourself, who do I want to be right now?  What is it I can do? What can I take from this experience? What is your purpose in what you are doing? Is it self-preservation? Helping others? Wanting to make people laugh? Teach them? Inspire them? Provoke them?

Notice what gives you energy, what people have said are your strengths and see how to use them in new ways during this utterly novel, weird time.
 

What to do in high stress

Who finishes a marathon? It isn’t the most physically fit. Research shows us there are two key ingredients to completing and winning a race. You know the first one— “Will Power,” the strong determination to do something difficult. The second ingredient is lesser known and is called “Way Power.” Way Power is having a goal, the commitment to reach it, and an ability to think through multiple pathways toward that goal. When Plan A fails, if you have Plans B, C, D & E, you are far more likely to win.

What does this have to do with managing our fear? When we are afraid, we need multiple pathways to take us toward meeting (getting to know) and mastering our fear. It isn’t all or nothing, it’s reducing it five percent. Then the next five percent. One path works better for one person; find the one that appeals to you the most. Then the one that appeals to you second, then third.

We are all stronger than we know. Here are five possible paths to help meet and master fear.

We are facing an overwhelming challenge or task: what do marathoners do that we can do?

1. Control breathing and physiology
   • Slow your breath, pulling the air deeper inside increases the oxygen levels in your blood which helps counter the cortisol and other “threat” responses that drive up physiological reactions.
   • Nutrition and hydration are crucial for sustained high performance in any high stress challenge.
   • Keep yourself moving, no matter what the resistance, exercise can be a way to reduce the fear response.

At times, fear can feel overwhelming. How can we help ourselves when it just feels too big?

2. Meet and Manage fear
   • Emotions hit us in waves, when you can’t stop it, ride it out. Don’t thrash in the water. Water can hold us up, let the wave lift you up, then pass and let you settle down.
   • Fear is uncomfortable but can’t kill you. Try not to be contagious to others.
   • See it, name it. Co-exist with it. If it won’t recede right now, that’s just what is. Imagine driving a car. Put fear in the passenger seat, present, but don’t let it drive your decisions and actions.

How can we manage to be “bigger” than our fear?

3. Win the inner game
   • Parts of you are in distress and in a high fear state. But is it 100%? Find a deeper part of you that can be compassionate to the parts of you that are afraid.
   • Be aware of your inner dialogue. Talk to yourself as you would a friend or your child, if you are being nasty or mean to yourself, please stop. It’s not fair.
   • Find a “Mantra” a phrase or sentence you can repeat over and over. It might be as simple as, “I’ll be okay,” or, “We’re tough!” or “we’re going to make it through.” Find the part of you that is strong, what does it want to tell you?

Like a marathon, we are in this for the long haul. How do we keep going and going?

4. Pace yourself through the race to finish and win
   • Do not go all out. Keep your reserves. There are times you must move at 80% speed.
   • Learn to expend only the energy you need; you can recover by relaxing while running. 10 second breaks actually help. Take a three-breath- break.
   • “Draft” on another. When you are tired, let someone else lead and absorb some of the resistance for a while.

We will be stronger at the end.

5. Connect with deeper values and purpose.
   • We are in this race together and can be more connected. Physical isolation does not mean social disconnection, keep reaching out and responding to others.
   • Extreme effort brings out the best or the worst in us. Appreciate when you are at your best. Accept and then challenge yourself when you slip. And when you slip again.
   • Remember what really matters, pull on the meaning of what you can be learning now. Live it. If it’s family, get off the computer.

We have never faced anything like this before. Now is the time to grow the seeds of our courage and strength. Find your feet and your second wind, then your third. And we will come out stronger and more deeply connected to those we love, and our community. I recently saw a poster that speaks to us now. It was an action shot of a runner, racing toward us flat out, with two titanium prosthetic lower legs. The message is perfect. “Don’t think about what you cannot do. Think about what you can.”

When you hit the wall – maybe it’s like the sound barrier – once you are through there is much less resistance and you can fly faster than you ever imagined.

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Resources:

Tempered by Fire: Beyond Resilience

1. Richard Tedeschi and Lawrence Calhoun
2. https://www.psychologytoday.com/us/blog/beyond-resilience/201309/tempered-fire

PTGrowth: Tedeschi and Calhoun

Not just survive or persevering:

• It’s the capacity to Reflect, Grow and Shift your perspective
• Can help you discover your values
• Recognize and embrace new opportunities
• Stronger relationships with loved ones and fellow survivors
• Cultivate inner strengths, knowing than can
• Appreciation for life

What it looks like:

• Recognizing your own strength
• Greater appreciation for the value or your life
• Changes in how you relate to people
• Recognizing new opportunities, priorities and pathways in life &emdash; and helping others do the same.

Links:

Tempered by Fire: Beyond Resilience

Richard Tedeschi and Lawrence Calhoun

https://www.psychologytoday.com/us/blog/beyond-resilience/201309/tempered-fire

From NIH, the National Institute of Health, US

https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml#part_145371

Post-Traumatic Stress Disorder

Overview

Post-traumatic stress disorder (PTSD) is a disorder that develops in some people who have experienced a shocking, scary, or dangerous event.

It is natural to feel afraid during and after a traumatic situation. Fear triggers many split-second changes in the body to help defend against danger or to avoid it. This “fight-or-flight” response is a typical reaction meant to protect a person from harm. Nearly everyone will experience a range of reactions after trauma, yet most people recover from initial symptoms naturally. Those who continue to experience problems may be diagnosed with PTSD. People who have PTSD may feel stressed or frightened, even when they are not in danger.

Signs and Symptoms

While most but not all traumatized people experience short term symptoms, the majority do not develop ongoing (chronic) PTSD. Not everyone with PTSD has been through a dangerous event. Some experiences, like the sudden, unexpected death of a loved one, can also cause PTSD. Symptoms usually begin early, within 3 months of the traumatic incident, but sometimes they begin years afterward. Symptoms must last more than a month and be severe enough to interfere with relationships or work to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.

A doctor who has experience helping people with mental illnesses, such as a psychiatrist or psychologist, can diagnose PTSD.

To be diagnosed with PTSD, an adult must have all of the following for at least 1 month:

• At least one re-experiencing symptom
• At least one avoidance symptom
• At least two arousal and reactivity symptoms
• At least two cognition and mood symptoms

Re-experiencing symptoms include:

• Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating
• Bad dreams
• Frightening thoughts

Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms.

Avoidance symptoms include:

• Staying away from places, events, or objects that are reminders of the traumatic experience
• Avoiding thoughts or feelings related to the traumatic event

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.

Arousal and reactivity symptoms include:

• Being easily startled
• Feeling tense or “on edge”
• Having difficulty sleeping
• Having angry outbursts

Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating.

Cognition and mood symptoms include:

• Trouble remembering key features of the traumatic event
• Negative thoughts about oneself or the world
• Distorted feelings like guilt or blame
• Loss of interest in enjoyable activities

Cognition and mood symptoms can begin or worsen after the traumatic event but are not due to injury or substance use. These symptoms can make the person feel alienated or detached from friends or family members.

It is natural to have some of these symptoms for a few weeks after a dangerous event. When the symptoms last more than a month, seriously affect one’s ability to function, and are not due to substance use, medical illness, or anything except the event itself, they might be PTSD. Some people with PTSD don’t show any symptoms for weeks or months. PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.

Do children react differently than adults?

Children and teens can have extreme reactions to trauma, but some of their symptoms may not be the same as adults. Symptoms sometimes seen in very young children (less than 6 years old), these symptoms can include:

• Wetting the bed after having learned to use the toilet
• Forgetting how to or being unable to talk
• Acting out the scary event during playtime
• Being unusually clingy with a parent or other adult

Older children and teens are more likely to show symptoms similar to those seen in adults. They may also develop disruptive, disrespectful, or destructive behaviors. Older children and teens may feel guilty for not preventing injury or deaths. They may also have thoughts of revenge.

Risk Factors

Anyone can develop PTSD at any age. This includes war veterans, children, and people who have been through a physical or sexual assault, abuse, accident, disaster, or other serious events. According to the National Center for PTSD, about 7 or 8 out of every 100 people will experience PTSD at some point in their lives. Women are more likely to develop PTSD than men, and genes may make some people more likely to develop PTSD than others.

Not everyone with PTSD has been through a dangerous event. Some people develop PTSD after a friend or family member experiences danger or harm. The sudden, unexpected death of a loved one can also lead to PTSD.

Why do some people develop PTSD and other people do not?

It is important to remember that not everyone who lives through a dangerous event develops PTSD. In fact, most people will not develop the disorder.

Many factors play a part in whether a person will develop PTSD. Some examples are listed below. Risk factors make a person more likely to develop PTSD.

Other factors, called resilience factors, can help reduce the risk of the disorder.

Some factors that increase risk for PTSD include:

• Living through dangerous events and traumas
• Getting hurt
• Seeing another person hurt, or seeing a dead body
• Childhood trauma
• Feeling horror, helplessness, or extreme fear
• Having little or no social support after the event
• Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home
• Having a history of mental illness or substance abuse

Some factors that may promote recovery after trauma include:

• Seeking out support from other people, such as friends and family
• Finding a support group after a traumatic event
• Learning to feel good about one’s own actions in the face of danger
• Having a positive coping strategy, or a way of getting through the bad event and learning from it
• Being able to act and respond effectively despite feeling fear

Researchers are studying the importance of these and other risk and resilience factors, including genetics and neurobiology. With more research, someday it may be possible to predict who is likely to develop PTSD and to prevent it.

From the Mayo Clinic:

https://www.mayoclinic.org/diseases-conditions/post-traumatic-stress-disorder/symptoms-causes/syc-20355967

Overview

Post-traumatic stress disorder (PTSD) is a mental health condition that's triggered by a terrifying event — either experiencing it or witnessing it. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event.

Most people who go through traumatic events may have temporary difficulty adjusting and coping, but with time and good self-care, they usually get better. If the symptoms get worse, last for months or even years, and interfere with your day-to-day functioning, you may have PTSD.

Getting effective treatment after PTSD symptoms develop can be critical to reduce symptoms and improve function.

Symptom:

Post-traumatic stress disorder symptoms may start within one month of a traumatic event, but sometimes symptoms may not appear until years after the event. These symptoms cause significant problems in social or work situations and in relationships. They can also interfere with your ability to go about your normal daily tasks.

PTSD symptoms are generally grouped into four types: intrusive memories, avoidance, negative changes in thinking and mood, and changes in physical and emotional reactions. Symptoms can vary over time or vary from person to person.

Intrusive memories

Symptoms of intrusive memories may include:

• Recurrent, unwanted distressing memories of the traumatic event
• Reliving the traumatic event as if it were happening again (flashbacks)
• Upsetting dreams or nightmares about the traumatic event
• Severe emotional distress or physical reactions to something that reminds you of the traumatic event

Avoidance

Symptoms of avoidance may include:

• Trying to avoid thinking or talking about the traumatic event
• Avoiding places, activities or people that remind you of the traumatic event

Negative changes in thinking and mood

Symptoms of negative changes in thinking and mood may include:

• Negative thoughts about yourself, other people or the world
• Hopelessness about the future
• Memory problems, including not remembering important aspects of the traumatic event
• Difficulty maintaining close relationships
• Feeling detached from family and friends
• Lack of interest in activities you once enjoyed
• Difficulty experiencing positive emotions
• Feeling emotionally numb

Changes in physical and emotional reactions

Symptoms of changes in physical and emotional reactions (also called arousal symptoms) may include:

• Being easily startled or frightened
• Always being on guard for danger
• Self-destructive behavior, such as drinking too much or driving too fast
• Trouble sleeping
• Trouble concentrating
• Irritability, angry outbursts or aggressive behavior
• Overwhelming guilt or shame

Author: Catherine L. Leon with Contribution from C.J. Hunter, M.A.

Edited by Dr. Barry Barmann, Ph.D.

https://www.theravive.com/therapedia/posttraumatic-stress-disorder-(ptsd)-dsm--5-309.81-(f43.10)

Post-traumatic Stress Disorder (PTSD) DSM-5 309.81 (F43.10)

DSM-5 Category: Trauma and Stressor-Related Disorders

Introduction

Under DSM-5, post-traumatic stress disorder (PTSD) is an anxiety disorder that develops in relation to an event which creates psychological trauma in response to actual or threatened death, serious injury, or sexual violation.

The exposure must involve directly experiencing the event, witnessing the event in person, learning of an actual or threatened death of a close family member or friend, or repeated first-hand, extreme exposure to the details of the event.

A formal diagnosis of PTSD is made when the symptoms cause clinically significant distress or impairment in social and/or occupational dysfunction for a period of at least one month. The symptoms cannot be due to a medical condition, medication, or drugs or alcohol.

PTSD Symptoms

PTSD symptoms may include nightmares, flashbacks, sleep disturbance, mood disorders, suicidal ideation, avoidance, and hyper-arousal in response to trauma-related stimuli.

Hyper-arousal may include an increase in blood pressure and heart rate, hyperventilating, mood swings, fatigue, or insomnia when a memory of the event is triggered by some type of internal (cognition) or external (environmental) stimulus.

Common symptoms related to PTSD would include insomnia, attention deficit problems, and anhedonia. Common comorbid disorders are depression, anxiety, and substance addiction.

Under DSM-5, for those older than six years of age, PTSD includes four clusters of symptoms (APA, 2013):

• Re-experiencing the event — Recurrent memories of the event, traumatic nightmares, dissociative reactions, prolonged psychological distress
• Alterations in arousal — Aggressive, reckless or self-destructive behavior, sleep disturbances, hypervigilance
• Avoidance — Distressing memories, thoughts, or reminders of the event.
• Negative alterations in cognition and mood — Persistent negative beliefs, distorted blame, or trauma-related emotions; feelings of alienation and diminished interest in life

The duration of these symptoms (which cause clinically significant distress or impairment in social, occupational or other important areas of functioning) must occur for one month or longer. In addition, the disturbance cannot be attributed to a substance or medical condition.

PTSD Dissociative Subtype is used when the person has prominent dissociative symptoms. These dissociative symptoms include depersonalization, in which the person feels like an outside observer or detached from oneself; and derealization, in which the world seems unreal, distant or distorted.