Depersonalization disorder



Depersonalization Disorder 811
Photo by: James Steidl

Definition

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 , 4th 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 associated with 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; "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 differs from "derealization," which is a dissociative symptom 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.

Description

A person suffering from 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.

Causes and symptoms

Causes

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.

Findings in 2002 indicate that emotional abuse in particular is a strong predictor 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 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.

No specific genes have been associated with susceptibility to depersonalization disorder as of early 2002. It is possible that a genetic factor will be identified in the future.

NEUROBIOLOGICAL. 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 a symptom that involves differences in sensory perception and subjective experiences.

HISTORICAL. 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.

Symptoms

The symptoms of depersonalization disorder have been described earlier. Although DSM-IV-TR does not specify a list of primary symptoms of depersonalization, British 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.

DSM-IV-TR notes that patients with depersonalization disorder frequently score high on measurements of hypnotizability.

Demographics

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 U.S. 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.

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.

Diagnosis

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, or 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 semi-structured 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.

Treatments

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-behavioral 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). As of 1999, newer, promising medications called selective serotonin reuptake inhibitors (SSRIs) became available. Some SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil). SSRIs act on brain chemicals that nerve cells use to send messages to each another. These chemical messengers ( neurotransmitters ) are released by one nerve cell and taken up by others. Those that are not taken up by other cells are taken up by the ones that released them. This is called "reuptake." SSRIs work by preventing the reuptake of serotonin—an action which allows more serotonin to be taken up by nerve cells.

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.

Prognosis

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.

Prevention

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. It is also hopeful that further neurobiological research will lead to the development of medications or other treatment modalities for preventing, as well as treating, depersonalization.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association, 2000.

"Depersonalization Disorder." Section 15, Chapter 188, in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 2001.

Ellenberger, Henri. The Discovery of the Unconscious. New York: Basic Books, Inc., 1970.

Herman, Judith, MD. Trauma and Recovery . 2nd ed., revised. New York: Basic Books, 1997.

Medical Economics staff. Physicians' Desk Reference. 56th ed. Montvale, NJ: Medical Economics Company, 2002.

Stout, Martha, PhD. The Myth of Sanity: Tales of Multiple Personality in Everyday Life. New York: Penguin Books, 2001.

PERIODICALS

Berrios, G. E., and M. Sierra. "Depersonalization: A Conceptual History." Historical Psychiatry 8 (June 1997): 213-229.

Guralnik, O., J. Schmeidler, and D. Simeon. "Feeling Unreal: Cognitive Processes in Depersonalization." American Journal of Psychiatry 157 (January 2000): 103-109.

Lambert, M. V., C. Senior, M. L. Phillips, and others. "Visual Imagery and Depersonalisation." Psychopathology 34 (September-October 2001): 259-264.

Phillips, M. L., N. Medford, C. Senior, and others. "Depersonalization Disorder: Thinking Without Feeling." Psychiatry Research 108 (December 30, 2001): 145-160.

Sierra, M., and others. "Lamotrigine in the Treatment of Depersonalization Disorder." Journal of Clinical Psychiatry 62 (October 2001): 826-827.

Sierra, M., and G. E. Berrios. "The Phenomenological Stability of Depersonalization: Comparing the Old with the New." Journal of Nervous and Mental Disorders 189 (September 2001): 629-636.

Simeon, D., and others. "Personality Factors Associated with Dissociation: Temperament, Defenses, and Cognitive Schemata." American Journal of Psychiatry 159 (March 2002): 489-491.

Simeon, D., O. Guralnik, E. A. Hazlett, and others. "Feeling Unreal: A PET Study of Depersonalization Disorder." American Journal of Psychiatry 157 (November 2000): 1782-1788.

Simeon, D., O. Guralnik, M. Knutelska, and others. "Hypothalamic-Pituitary-Adrenal Axis Dysregulation in Depersonalization Disorder." Neuropsychopharmacology 25 (November 2001): 793-795.

Simeon, D., O. Guralnik, and J. Schmeidler. "Development of a Depersonalization Severity Scale." Journal of Traumatic Stress 14 (April 2001): 341-349.

Simeon, D., O. Guralnik, J. Schmeidler, and others. "The Role of Childhood Interpersonal Trauma in Depersonalization Disorder." American Journal of Psychiatry 158 (July 2001): 1027-1033.

Simeon, D., D. J. Stein, and E. Hollander. "Treatment of Depersonalization Disorder with Clomipramine." Biological Psychiatry 44 (August 15, 1998): 302-303.

Stanton, B. R., A. S. David, A. J. Cleare, and others. "Basal Activity of the Hypothalamic-Pituitary-Adrenal Axis in Patients with Depersonalization Disorder." Psychiatry Research 104 (October 2001): 85-89.

Zanarini, M. C., and others. "The Dissociative Experiences of Borderline Patients." Comparative Psychiatry 41 (May-June 2000): 223-227.

ORGANIZATIONS

International Society for the Study of Dissociation (ISSD). 60 Revere Drive, Suite 500, Northbrook, IL 60062. (847) 480-0899. Fax: (847) 480-9282. <www.issd.org> .

National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. <www.nimh.nih.gov> .

National Organization for Rare Disorders, Inc. P. O. Box 8923, New Fairfield, CT 06812-8923. (203) 746-6518. <www.rarediseases.org> .

Society for Traumatic Stress Studies. 60 Revere Dr., Ste. 500, Northbrook, IL 60062. (708) 480-9080.

Rebecca J. Frey, Ph.D.



User Contributions:

Carole
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Feb 16, 2008 @ 3:15 pm
My 18-year-old daughter just informed me last night that she feels she has this, and has had it since she was much younger. She doesn't experience anything "out of body". I used to experience this when I was younger, too. I felt like my body was extremely tiny, and would feel that as a small person I could float. I don't remember anything traumatic in my life or my daughter's that might have caused this.
tom
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Oct 16, 2008 @ 11:23 pm
Im so scared. i was smoking weed on aug 5th 2008 and i took to much in and i started choughing and chocking and somthing popped in my head above my left ear. i came inside to tell my mom i turned white as a gost and my heart was beating crazy like i was having a heart attack i was checked out. i had an mri and mra of my brain. 2 katscans of my brain.ekg of my heart.ecko cardogram of my heart.coreated artry in my neck.. everything you can think of..N also my blood and urin.. i have anexity now and panic disorders. my sight seems funny like a good example taking the clothes out of the laUndry aND putting them in the dryer i have to ask myself if im really doing that. its scarey becuase i was smoking weed at the time. i just dont feel like me at all. will i get better.. i take klonpoin for my anexity. do i need an antidepression? how will i get better iits now october and im going crazy. everyday im going to another doctor i cant live like this. im 18 years old. im a senior and im missing to much school. i have weird numbing in my head where i popped somthing. which all my tests came back normal. thank god! so there was no pop but i no i popped somthing.. if someone can help me out i would reaLLY appractiee it. ill do anything to be the old me i was 3 months ago. im not the hopistal type person but thats been my 2nd home lately im almost there 3 timeso out of the week i get checked and discharged..i just want to no is it so much to ask for to feel better? i want to be a young adult and enjoy it! thanks again if you can help me out!
debbie710
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Mar 8, 2009 @ 5:05 am
I have suffered from severe depression and recently tried to commit suicide. I recovered well and thought I was improving when these experiences started happening to me. I see myself...and the whole room. I see her so often I named her Gladys. I panic when I see her or get very upset (crying). My husband doesn't like to leave me alone, but he has to go to work. So, I get babysitters...my mother, my kids etc. I take prozac, risperadol, and depokote. I also have a seizure disorder,fibromyalgia, IBS, asthma and herniated discs in myback. Life for me is out of control. I had an accident with my car, because I wasn't used to the meds. Can anyone help or relate at all? I go weekly for therapy. I was hospitalized twice.
zath
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Aug 9, 2009 @ 6:06 am
well
to you all
meds are not the way out but it is a step on the way
other steps are
1) accepting the case
2) not to watch yourself
3) not to test how intensive it is
4) get busy doing anything else

then it will go away
and u will never feel that it went away because u were doing step 2 and step 3 mentioned before
Bob
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Aug 12, 2009 @ 7:07 am
Hi all, i had Depersonalization disorder when i was 15, but i found that it only happened when i smoked pot, i just assumed everyone felt like this when they were high but i was obviously wrong, at 16 i stopped smoking untill one day i had the tinest hit from a pipe and that was me. Depersonalized for about 6 months and i was so scared but i felt i had to overcome this myself and only told this to my close friends who helped me. So all i done was really accepted that i would be like this forever and just went with it, its very hard especially talking to people but you just have to face it. Also i was the type who would come home and sit in my room every night but i started going out and excersising which i think helped. thankfully it just started to go away and now i feel great.

My advice would be if you have Depersonalization disorder, talk to people close to you (although they wont fully understand) and try not to fuss about it and think of it in a positive way because you are experiencing life in a new way and try to stay as positive as you can. and Trust me it WILL go away.
Maude
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Aug 24, 2009 @ 5:17 pm
Hi guys, im 25years old and a i year and a half ago i ran away from my husband who abused me for about 4years. It got to the point where my life was in danger which fueled the strenght to leave. I was ok for the couple following months and then bam, extreme anxiety hits, depression..flashbacks, nightmares, fear of going crazy and of course depersonalization. I didnt know what it was at first, this weird feeling of being a spectator of your own life, being in a dream, "being on cruise control" like a robot. I was doing dishes and wasnt even "feeling like" i was doing anything. I was walking and not even aware of it. I absolutely hate it but i realised that YOU HAVE TO NOT give it power. Which means, try to ignore it, push yourself to keep on going with your life like it wasnt there. IF you fear it, you will panic and make yourself worst. I believe it is a form of panic/anxiety. And to me, i realise it is related with my menstrual cycle (if you are a woman, you probably can relate) as well as whenever my bf and i get into an argument and there is yelling. Try to observe when it happens, what seems to trigger it. Watch your sleep, make sure you get enough of it. But i am here to tell you, the key is to fight it, dont let it scare you or overwhelm you, push yourself harder and do the things that you would normally do. It goes away for me and then comes back but in my heart i know it always goes away at some point. Be strong, you are not alone.
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Aug 14, 2010 @ 12:00 am
Hey Im Cheyenne Im 13 years old and I recently found out about this disorder from my frined who has it. I researched it and it is exactly how Ive been feeling for the past year. I also felt it when I was about 8-11 but not as sever as now. In a lot of these people say its from smoking pot, but Ive never smoked in my life. I am also depressed and have anxiety and panic attacks. Its all so overwhelming. IF someone could please email me who also has to just talk about it? Thanks
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Aug 18, 2010 @ 11:23 pm
I'm 15 and I recently attempted suicide and have been diagnosed with depression.
I have been experiencing symptoms of depersonalization disorder my entire life, in fact my earliest memory was when I had one of my "moments" as I've always called them. It's been scaring me my entire life. I truly felt like the only person who has gone threw this, but after speaking to my therapist and researching online I realize how many people suffer from this to many different degrees. I would suggest to anyone on this site who believes they have depersonalization disorder or any other mental illness who hasn't spoken to a therapist or to their doctor to do so asap.
tom
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Jun 21, 2011 @ 3:15 pm
tom im going through the same thing seeing as its been two years i dont think you will reply but if you see this how did you get through it? my name is also tom and i had the SAME exact thing happen to me...thats weird!
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Jun 22, 2011 @ 9:21 pm
Hi,
Im Melissa. I am 13 and I have recently discovered this disorder. I am very afraid I have severe Depersonalization disorder. Im too afraid to tell anyone. I feel like this about ninty precent of the time. Please if you could email or tell me where to get help. That would be great. Anyone who wants to talk and share experiences. Thanks so much. wawhateveryouneed@yahoo.com

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