Depersonalization is a state in which the individual ceases to perceive the reality of the self or the environment. The patient feels that his or her body is unreal, is changing, or is dissolving; or that he or she is outside of the body.
Depersonalization disorder is classified by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision, also known as the DSM-IV-TR as one of the dissociative disorders. These are mental disorders in which the normally well-integrated functions of memory, identity, perception, and consciousness are separated (dissociated). The dissociative disorders are usually connected to trauma in the recent or distant past, or with an intense internal conflict that forces the mind to separate incompatible or unacceptable knowledge, information, or feelings. In depersonalization disorder, the patient’s self-perception is disrupted. Patients feel as if they are external observers of their own lives, or that they are detached from their own bodies. Depersonalization disorder is sometimes called “depersonalization neurosis.”
Depersonalization as a symptom may occur in panic disorder, borderline personality disorder, post-traumatic stress disorder (PTSD), acute stress disorder , or another dissociative disorder. The patient is not given the diagnosis of depersonalization disorder if the episodes of depersonalization occur only during panic attacks or following a traumatic stressor.
The symptom of depersonalization can also occur in normal individuals under such circumstances as sleep deprivation, the use of certain anesthetics, experimental conditions in a laboratory (experiments involving weightlessness, for example), and emotionally stressful situations (such as taking an important academic examination or being in a traffic accident). One such example involves some of the rescue personnel from the September 11, 2001, terrorist attacks on the World Trade Center and the Pentagon. These individuals experienced episodes of depersonalization after a day and a half without sleep. A more commonplace example is the use of nitrous oxide, or “laughing gas,” as an anesthetic during oral surgery. Many dental patients report a sense of unreality or feeling of being outside their bodies during nitrous oxide administration.
To further complicate the matter, depersonalization may be experienced in different ways by different individuals. Common descriptions include a feeling of being outside one’s body; “floating on the ceiling looking down at myself;” feeling as if one’s body is dissolving or changing; feeling as if one is a machine or robot; an “unreal” feeling that one is in a dream or that one “is on automatic pilot.” Most patients report a sense of emotional detachment or uninvolvement, or a sense of emotional numbing. Depersonalization is distinct from a dissociative symptom called derealization, in which people perceive the external world as unreal, dreamlike, or changing. The various ways that people experience depersonalization are related to their bodies or their sense of self.
Depersonalization is a common experience in the general adult population. However, when a patient’s symptoms of depersonalization are severe enough to cause significant emotional distress, or interfere with normal functioning, the criteria of the DSM-IV-TR for depersonalization disorder are met.
A person with depersonalization disorder experiences subjective symptoms of unreality that make him or her uneasy and anxious. “Subjective” is a word that refers to the thoughts and perceptions inside an individual’s mind, as distinct from the objects of those thoughts and perceptions outside the mind. Because depersonalization is a subjective experience, many people who have chronic or recurrent episodes of depersonalization are afraid others will not understand if they try to describe what they are feeling, or will think they are “crazy.” As a result, depersonalization disorder may be underdiagnosed because the symptom of depersonalization is underreported.
Depersonalization disorder, like the dissociative disorders in general, has been regarded as the result of severe abuse in childhood. This can be of a physical, emotional, and/or sexual nature.
Trauma and emotional abuse in particular are strong predictors of depersonalization disorder in adult life, as well as of depersonalization as a symptom in other mental disorders. Analysis of one study of 49 patients diagnosed with depersonalization disorder indicated much higher scores than the control subjects for the total amount of emotional abuse endured and for the maximum severity of this type of abuse. The researchers concluded that emotional abuse has been relatively neglected by psychiatrists compared to other forms of childhood trauma.
It is thought that abuse in childhood or trauma in adult life may account for the distinctive cognitive (knowledge-related) profile of patients with depersonalization disorder. These patients have significant difficulties in focusing their attention, with spatial reasoning, and with short-term visual and verbal memory. However, they have intact reality testing. (Reality testing refers to a person’s ability to distinguish between their internal experiences and the objective reality of persons and objects in the outside world.) Otherwise stated, a patient with depersonalization disorder may experience his/her body as unreal, but knows that “feelings aren’t facts.” The DSM-IV-TR specifies intact reality testing as a diagnostic criterion for depersonalization disorder.
The causes of depersonalization disorder are not completely understood. Recent advances in brain imaging and other forms of neurological testing, however, have confirmed that depersonalization disorder is a distinct diagnostic entity and should not be considered a subtype of PTSD. A recent study using brain-imaging techniques found that patients with depersonalization disorder do not process emotional information in the same way as healthy controls, and their differences on brain imaging reflect their reported reduced or absent emotional response to verbal material that normally would elicit strong emotion, such as “There is a bomb inside the parcel.”
In the past few years, several features of depersonalization disorder have been traced to differences in brain functioning. A group of British researchers found that the emotional detachment that characterizes depersonalization is associated with a lower level of nerve-cell responses in regions of the brain that are responsible for emotional feeling; an increased level of nerve-cell responses was found in regions of the brain related to emotional regulation.
A group of American researchers concluded that patients with depersonalization disorder had different patterns of response to tests of the hypothalamic-pituitary-adrenal axis (HPA; the part of the brain involved in the “fight-or-flight” reaction to stress ) than did patients with PTSD. Other tests by the same research team showed that patients with depersonalization disorder can be clearly distinguished from patients with major depression by tests of the functioning of the HPA axis.
Other neurobiological studies involving positron emission tomography (PET) measurements of glucose (sugar) metabolism in different areas of the brain found that patients with depersonalization disorder appear to have abnormal functioning of the sensory cortex. The sensory cortex is the part of the brain that governs the senses of sight, hearing, and perceptions of the location of one’s body in space. These studies indicate that depersonalization is symptom that involves differences in sensory perception and subjective experiences. In the study of patients and their processing of emotional information, the authors found that in patients showed a similar response in the visual cortex to emotional and neutral verbal information. They did not appear to distinguish these two classes of material, which could either be because they have an overall reduced emotional response or because their response to neutral material is enhanced.
Depersonalization disorder may be a reflection of changes in people’s sense of self or personal identity within Western cultures since the eighteenth century. Historians of psychiatry have noted that whereas some mental disorders, such as depression, have been reported since the beginnings of Western medicine, no instances of the dissociative disorders were recorded before the 1780s. It seems that changes in social institutions and the structure of the family since the mid-eighteenth century may have produced a psychological structure in Westerners that makes individuals increasingly vulnerable to self disorders—as they are now called. Experiences of the unreality of one’s body or one’s self, such as those that characterize depersonalization disorder, presuppose a certain notion of how the self is presumed to feel. The emphasis on individualism and detachment from one’s family is a mark of adult maturity in contemporary Western societies that appears to be a contributing factor to the frequency of dissociative symptoms and disorders.
Although the DSM-IV-TR does not specify a list of primary symptoms of depersonalization, clinicians generally consider the triad of emotional numbing, changes in visual perception, and altered experience of one’s body to be important core symptoms of depersonalization disorder.
The DSM-IV-TR notes that patients with depersonalization disorder frequently score high on measurements of hypnotizability.
The lifetime prevalence of depersonalization disorder in the general population is unknown, possibly because many people are made anxious by episodes of depersonalization and afraid to discuss them with a primary care physician. One survey done by the National Institutes of Mental Health (NIMH) indicates that about half of the adults in the United States have had one or two brief episodes of depersonalization in their lifetimes, usually resulting from severe stress. About a third of people exposed to life-threatening dangers develop brief periods of depersonalization, as do 40% of psychiatric inpatients. Estimates of the prevalence of depersonalization disorder in the general population range from 2.4% to 20%.
Depersonalization disorder is diagnosed about twice as often in women as in men. It is not known, however, whether this sex ratio indicates that women are at greater risk for the disorder or if they are more likely to seek help for its symptoms, or both. Little information is available about the incidence of the disorder in different racial or ethnic groups.
Abuse —Physical, emotional, or sexual harm.
Depersonalization —A dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving; or that he or she is outside the body.
Depersonalization neurosis —Another name for depersonalization disorder.
Derealization —A dissociative symptom in which the external environment is perceived as unreal or dreamlike.
Dissociation —A reaction to trauma in which the mind splits off certain aspects of the traumatic event from conscious awareness. Dissociation can affect the patient’s memory, sense of reality, and sense of identity.
Dissociative disorders —A group of disorders marked by the separation (dissociation) of perception, memory, personal identity, and consciousness. Depersonalization disorder is one of five dissociative disorders defined by DSM-IV-TR.
Hypothalamic-pituitary-adrenal (HPA) system —A part of the brain involved in the human stress response. The HPA system releases cortisol, the primary human stress hormone, and neurotransmitters that activate other brain structures associated with the fight-or-flight reaction. The HPA system appears to function in abnormal ways in patients diagnosed with depersonalization disorder. It is sometimes called the HPA axis.
Reality testing —A phrase that refers to a person’s ability to distinguish between subjective feelings and objective reality. A person who knows that their body is real even though they may be experiencing it as unreal, for example, is said to have intact reality testing. Intact reality testing is a DSM-IV-TR criterion for depersonalization disorder.
Selective serotonin reuptake inhibitors —Commonly prescribed drugs for treating depression. SSRIs affect the chemicals that nerves in the brain use to send messages to one another.
Serotonin —A widely distributed neurotransmitter that is found in blood platelets, the lining of the digestive tract, and in the brain where it works in combination with norepinephrine. It causes very powerful contractions of smooth muscle, and is associated with mood, attention, emotions, and sleep. Low levels of serotonin are associated with depression.
Stress —A physical and psychological response that results from being exposed to a demand or pressure.
Stressor —A stimulus or event that provokes a stress response in an organism. Stressors can be categorized as acute or chronic, and as external or internal to the organism.
Subjective —Referring to a person’s unique internal thoughts and feelings, as distinct from the objects of those thoughts and feelings in the eternal world.
Tricyclic antidepressants (TCAs) —Antidepressant medications that have the common characteristic of a three-ring nucleus in their chemical structure. Imipramine and amitriptyline are examples of tricyclic antidepressants.
The diagnosis of depersonalization disorder is usually a diagnosis of exclusion. The doctor will take a detailed medical history, give the patient a physical examination, and order blood and urine tests in order to rule out depersonalization resulting from epilepsy, substance abuse , medication side effects, or recent periods of sleep deprivation.
There are several standard diagnostic questionnaires that may be given to evaluate the presence of a dissociative disorder. The Dissociative Experiences Scale (DES) is a frequently administered self-report screener for dissociation. The Structured Clinical Interview for DSM-IV Dissociative Disorders, or SCID-D, can be used to make the diagnosis of depersonalization disorder distinct from the other dissociative disorders defined by DSM-IV. The SCID-D is a semistructured interview, which means that the examiner’s questions are open-ended and allow the patient to describe experiences of depersonalization in some detail—distinct from simple yes-or-no answers.
In addition to these instruments, a six-item Depersonalization Severity Scale, or DSS, has been developed to discriminate between depersonalization disorder and other dissociative or post-traumatic disorders, and to measure the effects of treatment in patients.
Depersonalization disorder sometimes resolves on its own without treatment. Specialized treatment is recommended only if the symptoms are persistent, recurrent, or upsetting to the patient. Insight-oriented psychodynamic psychotherapy , cognitive-behavior therapy, and hypnosis have been demonstrated to be effective with some patients. There is, however, no single form of psychotherapy that is effective in treating all patients diagnosed with depersonalization disorder.
Medications that have been helpful to patients with depersonalization disorder include the benzodiazepine tranquilizers, such as lorazepam (Ativan), clorazepate (Tranxene), and alprazolam (Xanax), and the tricyclic antidepressants , such as amitriptyline (Elavil), doxepin (Sinequan), and desipramine (Norpramin). Selective serotonin reuptake inhibitors (SSRIs) , which include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil ), may also be effective. SSRIs affect levels of the brain chemicals that nerve cells use to send messages to each another. These chemical messengers, called (neurotransmitters ), are released by one nerve cell and taken up by others. If the receiving cell does not take up the chemical, the sending cell will take it up, a process called “reuptake.” SSRIs work by preventing the reuptake of serotonin, leaving more serotonin for nerve signaling. Serotonin signaling is associated with feelings of well-being.
Unfortunately, there have been very few well-designed studies comparing different medications for depersonalization disorder. Because depersonalization disorder is frequently associated with trauma, effective treatment must include other stress-related symptoms, as well.
Relaxation techniques have been reported to be a beneficial adjunctive treatment for persons diagnosed with depersonalization disorder, particularly for those who are worried about their sanity.
The prognosis for recovery from depersonalization disorder is good. Most patients recover completely, particularly those who developed the disorder in connection with traumas that can be explored and resolved in treatment. A few patients develop a chronic form of the disorder; this is characterized by periodic episodes of depersonalization in connection with stressful events in their lives.
Some clinicians think that depersonalization disorder has an undetected onset in childhood, even though most patients first appear for treatment as adolescents or young adults. Preventive strategies could include the development of screening techniques for identifying children at risk, as well as further research into the effects of emotional abuse on children.
Further neurobiological research may lead to the development of medications or other treatment modalities for preventing, as well as treating, depersonalization.
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Rebecca J. Frey, PhD
Emily Jane Willingham, PhD