Insights: Dissociation And Panic Symptoms In Adolescence – Dr Emma Černis

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Panic disorder is very common in adolescents – affecting an estimated 3.5% of people aged between 17–19. But what is the relationship between dissociation and panic symptoms in this age group, and what would this mean for our understanding and treatment of them? Are there any processes that make dissociation more likely to be related to symptoms of panic?

We discussed these questions with Dr Emma Černis, co-author of a paper published in JCPP Advances (2024) titled The relationship between dissociation and panic symptoms in adolescence and the exploration of potential mediators. Dr Černis is Assistant Professor of Clinical Psychology at the University of Birmingham, and her research focuses on transdiagnostic dissociative experiences from a cognitive-behavioral perspective. We talked about the benefits of looking at dissociation by itself, the common misconceptions held about it, and how amenable dissociation is to a CBT approach. With dissociation often not covered in core training, this is a useful read for anyone interested in increasing their knowledge.

The most common conversation I have with clinicians (especially junior doctors, recently), is that they think it is really rare. In fact, depersonalization disorder is a kind of dissociation problem, and it’s as common as OCD or schizophrenia. We all know what OCD is, but most clinicians didn’t receive any training about dissociation in their core training, and they may feel less knowledgeable or confident in treating it. Given how common it is, it seems remiss that it isn’t covered in training.

Dissociation and panic symptoms – exploring the link

Tell us about this paper – what were its main aims?

This paper was a collaboration with Polly Waite, who is an expert in adolescent anxiety, Lottie Shipp, who is now doing a PhD in adolescent generalized anxiety disorder, and Alisa Musatova, who completed this research as part of her undergraduate degree at the University of Oxford. We wanted to understand the link between dissociative feelings and panic symptoms in young people. Depersonalization – the feeling that you’re somehow unreal or your body is detached or disconnected – is listed as one of the symptoms of panic disorder, but there hadn’t been an investigation into what the exact link is between panic and depersonalization, which is considered an example of a dissociative experience. We wanted to look not just at the relationship between dissociative experiences and panic disorder, but also what might mediate that. Are there particular processes making dissociation more likely to be related to panic symptoms, and which of these could be addressed in clinical practice?

My own theory (which I’m still building an evidence base for) is that dissociative experiences might trigger other mental health problems, because they might be interpreted in a way that causes other difficulties.

You mentioned mediating factors between dissociative experiences and panic disorder. What are they, and why focus on them?

The specific mediating processes that we investigated were cognitive appraisals of dissociation (the thoughts and beliefs people have about their dissociative experiences), emotion regulation strategies of cognitive reappraisal (changing the way you view a situation to alter its emotional impact) and expressive suppression (squashing your feelings down), and alexithymia (characterized by difficulty identifying and describing emotional states, alongside a tendency to focus attention externally; Bagby et al., 1994).

These came out of my work with adult groups. A lot of my previous work has been looking for the maintenance factors of dissociative experiences, because my main program of research is developing a translational treatment for transdiagnostic dissociative experiences. We can’t treat it if we don’t know what’s causing it; we can’t unstick it if we don’t know what’s keeping it stuck. Thinking about potential maintenance mechanisms for difficulties with emotions, people can sometimes feel a bit sensitive to or avoidant about experiencing emotions: they don’t feel they have a good capacity to manage and cope with stressful situations like negative emotions. That led to thinking about potentially related mediators like emotion regulation, which is why we looked at two different emotion regulation strategies within this paper as possible mediators.

Are there other mediating factors that you’d like to explore?

I’m applying for funding to run a study testing whether affect intolerance, rumination, and low self-efficacy are causal factors for dissociation. It would also look further into cognitive appraisals, which came out as quite important in this paper. It’s not just the experience that interests me, but also how we make sense of it following a cognitive behavioural approach.

Why do you think that clinicians and practitioners working with clients should be interested in this paper. Why is it helpful to them and for clinical practice generally?

Panic disorder is very common in adolescents. It affects an estimated 3.5% of 17-19 year-olds, and it can be quite disabling and horrible for them. There hadn’t been a real exploration of how dissociation fits into this, although I feel young people are getting wiser to dissociation. It’s definitely being discussed more online, albeit not always in the most accurate way. It’s especially worth being aware of dissociation if young people mention it, because they might have come across the word themselves and be offering that as helpful information to clinicians. It can be hard to know what to do if you’ve not heard of it before, or if you don’t know how it links to the problem they’re talking about. Whether you’ve had training on dissociation or not, this paper is useful for clinicians because understanding more about how dissociation relates to the panic symptoms can highlight that this could be an important focus when addressing panic disorder in practice.

Your research looks at dissociation from a wider perspective than trauma-based dissociation. Why is that?

My work differs in that I am looking at dissociation as a single transdiagnostic symptom in its own right. When you start doing that, you realize that trauma is a massively important aspect of dissociation, but there are many people who are having dissociative experiences that haven’t had trauma, or don’t want to call it that. They might not identify with being a survivor of trauma, and their dissociation might have built up from chronic stress, or a kind of sustained low-level burnout.

There are a few advantages to looking at dissociation this way. If we can understand how dissociation occurs in people who don’t identify as having had trauma, it might also help us understand how it comes from trauma. Secondly, if we understand the dissociation as a symptom in and of itself, it means we can better help people who come into the clinic saying “I feel really unreal, I feel really strange, and I want somebody to help me with it.” If we change the subject at that point by talking about trauma, you might lose that person.

It’s a bit controversial, though, and some people don’t like it. Historically, there’s been quite a turbulent dialogue around dissociation over the past few decades. There was a really vicious debate in the 90s and 00s between people who were saying that all dissociation is only trauma-based, and people who were pointing out that a lot of dissociation, particularly dissociative identity disorder, could be made worse by therapists assuming that it is necessarily trauma-based. It essentially turned into a debate about whether dissociation is real. I think, unfortunately, the result of all of that debate is that, now, if you start trying to talk about anything to do with dissociation that isn’t trauma, people think you’re suggesting that dissociation is not real, or that you are denying people’s trauma. I really don’t want to be misinterpreted like that, but just saying dissociation is caused by trauma isn’t a satisfactory answer for me: I want to know how it is caused. Why does trauma cause dissociative experiences in some people? How do some people without trauma come to experience it? What are the mechanisms making that happen? I also want people coming to services for help to have the option talk about their dissociation and not their trauma (whether or not they have any), if that’s what they want to focus on.

What were the most interesting or surprising findings in your opinion?

The most surprising thing for me was that the expressive suppression didn’t come out as a significant mediator. When you look at all the literature and talk to people with lived experience of dissociation, you’d expect that squashing down your feelings or suppressing them would be a surefire way to feel a bit dissociated. That might because of the short follow-up period in this study; perhaps there wasn’t enough time for things to change. I haven’t given up on it as a potential mediator, but it did surprise me that it didn’t come out.

One of the most important mediating factors was cognitive appraisals of dissociation. This supports the idea that we can take a cognitive-behavioral view of this problem: it is the interpretation of these feelings that is driving a lot of the panic symptoms for young people. That fits really neatly within the wheelhouse of a lot of clinicians whose day-to-day work is helping young people with their appraisals of situations.

In your experience what are the common misconceptions held by therapists or students about dissociation?

We’ve just finished a pilot of a survey asking about this. We asked undergraduates what their attitudes and beliefs were about dissociation. We’re about to roll that out to GCSE age students, and to clinicians in the NHS to see what disparities there are in people’s responses. From the data we’ve already got, a lot of undergraduates are finding that the information available online romanticizes or exaggerates dissociation. It’s portrayed as something that you can control, switch on and off, or which doesn’t have a massive impact on your day, like zoning out. Unfortunately, this returns to that old narrative where a lot of people dismiss it as fake or as something people are ‘putting on’. This impression doesn’t match with people’s lived experience, though, which is that it’s much more serious than people give it credit for. It’s uncontrollable and pervasive, in every element of their lives.

I work quite a lot with Joe Perkins, who has a lived experience of depersonalization disorder. He’s written a book about it (Life on Autopilot: A Guide to Living with Depersonalization Disorder), and he’s got a YouTube channel (DPD Diaries) describing his experiences. He’s told me that one of the most frustrating things from his perspective is that people tell him that he doesn’t seem unwell. There’s a misconception that if people can go through the motions and appear to function, everything must be ok and there’s no problem. But the distress is always there. It’s such a confusing and alarming set of feelings that when people don’t know what it is, I can see how it could cause other problems.

Clinical takeaways for practitioners

What are the key clinical implications to be aware of? What should therapists pay attention to specifically?

• Don’t jump to depression too quickly. It’s easy to recognize things we are familiar with. If somebody describes feeling numb, detached, and unable to feel emotions anymore, we’re likely to jump to depression and stop asking any more questions, because that fits a pattern in our heads. But people with dissociation and depression describe these experiences as feeling very different. They might say things like “I can’t access my emotions and it feels like they’ve been taken away from me. It’s different to feeling low and apathetic”. People can describe their experiences in some detail, make sure you give them a chance to tell you.

• Be curious and ask more questions when you’re working with young people presenting with panic symptoms, and make sure you really understand what is being described. It can be difficult for a young people to put dissociative experiences into words. Keep questioning and stay open minded until you’re sure you fully understand what this young person is describing.

• Dissociation is amenable to a CBT approach. There is a strong link between dissociative experiences and panic symptoms, so it’s worth making sure if it’s there. Ask about triggers for panic symptoms. If the young person doesn’t offer dissociation as a trigger, consider using open questions around how some people have these experiences, and they can also lead to sensations of panic. Have they ever experienced anything like that? How did they interpret those events? If dissociation is there – and related to the interpretation of these panic symptoms – psychoeducation about dissociation might be a really nice self-contained piece of work. Explain that it’s quite common, that it doesn’t mean that they’re going mad or that there’s something wrong with their brain. You can then teach them to challenge it in the same way as they would with a racing heart rate.

We hope this paper invites people working with adolescents to think more about dissociation and feel a bit more confident working with it.

What do you think the main challenges are for therapists who work with clients in this area, and what guidance would you give them?

• Finding high quality credible resources is a challenge. Many people aren’t trained in dissociation, and when you’re looking for resources it might be difficult to tell what is high-quality and trustworthy, and what may be a bit dubious. There are some very good resources, but not many.  The website www.mind.org.uk is a fantastic resource. I’ve seen Psychology Tools resources about dissociation as well, and they’re really good. I’m trying to develop my own little page where I’m collecting resources you can trust about dissociation, but unfortunately it’s just a holding page at the moment! It’s important to collect the best resources about dissociation, because I think young people have noticed that a lot of the material on social media is exaggerated.

• Don’t underestimate the importance of appraisal. For example, if you have jetlag, you know why everything feels strange: your body feels different and the environment seems too bright because your whole body is out of sync. But for a young person experiencing it for the first time, they wouldn’t necessarily know what it was, and this would affect their appraisals. They might think something was wrong with their brain, that they were going mad or about to collapse. It could easily lead to a panic presentation. Because young people are typically more aware of dissociation these days, they may well recognise dissociation being one of their triggers. However, I can forsee that there might then be a risk that they might then seek out and find information online that’s not reliable, and start to see dissociation as a larger problem. Challenging unhelpful appraisals around dissociation by providing alternative explanations for their feelings (e.g., that they might be particularly stressed, or hadn’t slept well) can start to normalize any subclinical experiences, and delivering psychoeducation about anxiety may be helpful for the stronger feelings preceding a panic attack.

Looking ahead

What’s next for you in this area?

A limitation of this paper is that even though we’ve used a longitudinal design, it’s still cross-sectional. So the next step is to test things in an experimental way. In other words, changing something to demonstrate that it causes something else to happen. I want to see if treating people’s affect intolerance has a downstream effect on people’s dissociation levels.

I noticed in my previous findings around alexithymia (difficulties recognizing or describing one’s emotions) people would report having great emotion perception, and it’s very difficult to tell with only a self-report measure whether they’re talking about their ability to identify their emotions, or whether they’re really talking about being hypervigilant to them. They think that people may be very good at noticing them because they’re always on high alert, and they don’t want to experience emotions, so they notice any that pop up.

That’s a concern with this study as well. In the case of expressive suppression, it might be that people are reporting that they’re not suppressing things, because they’re noticing every time they do it, because they’re so hypervigilant to their moods. I currently have no evidence about that – we didn’t measure or interview people about it – but that would fit cohesively with the clinical picture. This is why I want to take this active approach to changing people’s affect tolerance in therapy and seeing what happens. If I’m barking up the wrong tree, that’s what research is for, and we can at least rule out that idea.

Why is dissociation so fascinating to you? Why are you on this journey?

When I was working in a psychosis research group, we did a sub-study measuring depersonalization. I started writing up the data, and as I read more around the literature I was struck by two things. The first was that the experience itself was fascinating: its phenomenology is different to the mental health presentations I’d previously come across. It’s hard to describe – which makes it an interesting challenge – but once you start to understand what people are describing, there’s a sense of recognition and familiarity to things you’ve felt before. The second was a sense of injustice that we don’t have good answers about this area. People aren’t giving it the attention that it deserves. Many people have been stuck with dissociation for an incredibly long time, and there seems to be a real need to make some progress. There has been a lot of fantastic work, but overall the field is under-researched. The idea that any involvement you have in this area is going to make a difference and impact people’s lives is very compelling.

Further reading

Shipp, L., Mustatova, A., Černis, E., & Waite, P. (2024). The relationship between dissociation and panic symptoms in adolescence and the exploration of potential mediators. JCPP Advances, 4(1)

Brand, B. L. (2016). The Necessity of Clinical Training in Trauma and Dissociation. Journal of Depression and Anxiety, 5(4). https://doi.org/10.4172/2167-1044.1000251

Brand, B. L., Sar, V., Stavropoulos, P., Krüger, C., Korzekwa, M., Martínez-Taboas, A., & Middleton, W. (2016). Separating Fact from Fiction: An Empirical Examination of Six Myths About Dissociative Identity Disorder. Harvard Review of Psychiatry, 24(4), 257–270. https://doi.org/10.1097/HRP.0000000000000100

Černis, E., Antonović, M., Kamvar, R., Perkins, J., & Cernis, E. (2024). Depersonalisation-derealisation as a transdiagnostic treatment target: A scoping review of the evidence in anxiety, depression, and psychosis. OSF. https://doi.org/10.31234/osf.io/3gsbv

Černis, E., Beierl, E., Molodynski, A., Ehlers, A., & Freeman, D. (2021). A new perspective and assessment measure for common dissociative experiences: ‘Felt Sense of Anomaly’. PLOS ONE, 16(2), e0247037. https://doi.org/10.1371/journal.pone.0247037

Černis, E., Bird, J. C., Molodynski, A., Ehlers, A., & Freeman, D. (2021). Cognitive appraisals of dissociation in psychosis: A new brief measure. Behavioural and Cognitive Psychotherapy, 49(4), 472–484. https://doi.org/10.1017/S1352465820000958

Černis, E., Ehlers, A., & Freeman, D. (2022). Psychological mechanisms connected to dissociation: Generating hypotheses using network analyses. Journal of Psychiatric Research, 148, 165–173. https://doi.org/10.1016/j.jpsychires.2022.01.049

Černis, E., Evans, R., Ehlers, A., & Freeman, D. (2021). Dissociation in relation to other mental health conditions: An exploration using network analysis. Journal of Psychiatric Research, 136, 460–467. https://doi.org/10.1016/j.jpsychires.2020.08.023

Černis, E., Freeman, D., & Ehlers, A. (2020). Describing the indescribable: A qualitative study of dissociative experiences in psychosis. PLOS ONE, 15(2), e0229091. https://doi.org/10.1371/journal.pone.0229091

Černis, E., Loe, B. S., Lofthouse, K., Waite, P., Molodynski, A., Ehlers, A., & Freeman, D. (2023). Measuring dissociation across adolescence and adulthood: Developing the short-form Černis Felt Sense of Anomaly scale (ČEFSA-14). Behavioural and Cognitive Psychotherapy, 1–15. https://doi.org/10.1017/S1352465823000498

Ellickson-Larew, S., Stasik-O’Brien, S. M., Stanton, K., & Watson, D. (2020). Dissociation as a multidimensional transdiagnostic symptom. Psychology of Consciousness: Theory, Research, and Practice, 7(2), 126–150. https://doi.org/10.1037/cns0000218

Fung, H. W., Ross, C. A., Lam, S. K. K., & Hung, S. L. (2022). Recent research on the interventions for people with dissociation. European Journal of Trauma & Dissociation, 100299. https://doi.org/10.1016/j.ejtd.2022.100299

Hunter, E. C. M., Charlton, J., & David, A. S. (2017). Depersonalisation and derealisation: Assessment and management. BMJ, j745. https://doi.org/10.1136/bmj.j745

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. https://doi.org/10.1016/s0005-7967(03)00066-4

Hunter E.C.M., Sierra M., & David A.S. (2004). The epidemiology of depersonalisation and derealisation—A systematic review. Social Psychiatry and Psychiatric Epidemiology, 39(1), 9–18. Embase. https://doi.org/10.1007/s00127-004-0701-4

Lofthouse, M. K., Waite, P., & Černis, E. (2023). Developing an understanding of the relationship between anxiety and dissociation in adolescence. Psychiatry Research, 324, 115219. https://doi.org/10.1016/j.psychres.2023.115219

Nester, M. S., Hawkins, S. L., & Brand, B. L. (2022). Barriers to accessing and continuing mental health treatment among individuals with dissociative symptoms. European Journal of Psychotraumatology, 13(1), 2031594. https://doi.org/10.1080/20008198.2022.2031594

Perkins, J. (2021). Life on autopilot: A guide to living with depersonalization disorder ; foreword by Dr. Elaine Hunter and Professor Anthony David. Jessica Kingsley Publishers.

Şar, V. (2014). The many faces of dissociation: Opportunities for innovative research in psychiatry. Clinical Psychopharmacology and Neuroscience, 12(3), 171–179. http://dx.doi.org/10.9758/cpn.2014.12.3.171

Schauer, M., & Elbert, T. (2010). Dissociation Following Traumatic Stress: Etiology and Treatment. Zeitschrift für Psychologie / Journal of Psychology, 218(2), 109–127. https://doi.org/10.1027/0044-3409/a000018