Depersonalization disorder
Encyclopedia
Depersonalization disorder (DPD) is a dissociative disorder in which the sufferer is affected by persistent or recurrent feelings of depersonalization
and/or derealization
. Diagnostic criteria include persistent or recurrent experiences of feeling detached from one's mental processes or body. The symptom
s include a sense of automaton, going through the motions of life but not experiencing it, feeling as though one is in a movie, loss of conviction with one's identity, feeling as though one is in a dream, feeling a disconnection from one's body; out-of-body experience
, a detachment from one's body, environment and difficulty relating oneself to reality.
Occasional moments of mild depersonalization are normal; strong, severe, persistent, or recurrent feelings are not. A diagnosis of a disorder
is made when the dissociation
is persistent and interferes with the social and occupational functions necessary for everyday living. Depersonalization disorder is thought to be largely caused by severe traumatic lifetime events including childhood sexual, physical, and emotional abuse; accidents, war, torture, panic attacks and bad drug experiences. It is unclear whether genetics play a role; however, there are many neurochemical and hormonal changes in individuals suffering with depersonalization disorder.
As the core symptoms of the disorder are thought to protect the victim from negative stimuli, depersonalization disorder can be conceptualized as a defense mechanism. Depersonalization disorder is often comorbid with anxiety disorders, panic disorders, clinical depression
and bipolar disorder
.
Although depersonalization disorder is an alteration in the subjective experience of reality, it is not related to psychosis
, as sufferers maintain the ability to distinguish between their own internal experiences and the objective reality of the outside world. During episodic and continuous depersonalization, sufferers are able to distinguish between reality and fantasy, and their grasp on reality remains stable at all times.
Some of the more common factors that exacerbate dissociative symptoms are negative stimuli, stress, subjective threatening social interaction, and unfamiliar environments. Factors that tend to diminish symptoms are comforting interpersonal interactions, intense physical or emotional stimulation, and relaxation. Some factors are identified as relieving symptom severity such as diet or exercise; alcohol and fatigue are listed by others as worsening symptoms.
Fears of going crazy, brain damage, and losing control are common complaints. Individuals report occupational impairments as they feel they are working below their ability, and interpersonal troubles since they have an emotional disconnection from those they care about. Neuropsychological testing has shown deficits in attention
, short-term memory
and spatial-temporal reasoning
. Depersonalization disorder is associated with cognitive disruptions in early perceptual and attentional processes.
, social worker, clinical psychologist or other mental health professional
. Psychiatric assessment includes a psychiatric history
and some form of mental status examination
. Since some medical and psychiatric conditions mimic the symptoms of DPD, clinicians must differentiate between and rule out the following to establish a precise diagnosis: temporal lobe epilepsy
, panic disorder
, acute stress disorder, schizophrenia
, migraine
, drug use
, brain tumour or lesion
. No laboratory test for depersonalization disorder currently exists.
The diagnosis of DPD can be made with the use of the following interviews and scales:
The Structured Clinical Interview for DSM-IV
Dissociative Disorders (SCID-D) is widely used, especially in research settings. This interview takes about 30 minutes to 1.5 hours, depending on individual's experiences.
The Dissociative Experiences Scale
(DES) is a simple, quick, self-administered questionnaire that has been widely used to measure dissociative symptoms. It has been used in hundreds of dissociative studies, and can detect depersonalization and derealization experiences.
The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview which makes DSM-IV diagnoses of somatization disorder, borderline personality disorder and major depressive disorder, as well as all the dissociative disorders. It inquires about positive symptoms of schizophrenia, secondary features of dissociative identity disorder
, extrasensory experiences, substance abuse and other items relevant to the dissociative disorders. The DDIS can usually be administered in 30–45 minutes.
are as follows:
The DSM-IV-TR specifically recognizes three possible additional features of depersonalization disorder:
; major depressive disorder and panic
; and hallucinogen
ingestion. People who live in highly individualistic cultures may be more vulnerable to depersonalization, due to threat hypersensitivity and an external locus of control
.
One cognitive behavioral conceptualization is that misinterpreting normally transient dissociative symptoms as an indication of severe mental illness or neurological impairment leads to the development of the chronic disorder. This leads to a vicious cycle of heightened anxiety and symptoms of depersonalization and derealization.
Not much is known about the neurobiology of depersonalization disorder; however, there is converging evidence that the prefrontal cortex
may inhibit neural circuits that normally form the substrate of emotional experience. A PET scan
found functional abnormalities in the visual
, auditory, and somatosensory cortex, as well as in areas responsible for an integrated body schema. In an fMRI study of DPD patients, emotionally aversive scenes activated the right ventral prefrontal cortex
. Participants demonstrated a reduced neural response in emotion-sensitive regions, as well as an increased response in regions associated with emotional regulation. In a similar test of emotional memory
, depersonalization disorder patients did not process emotionally salient material in the same way as did healthy controls. In a test of skin conductance responses to unpleasant stimuli, the subjects showed a selective inhibitory mechanism on emotional processing.
Depersonalization disorder may be associated with dysregulation of the hypothalamic-pituitary-adrenal axis
, the area of the brain involved in the "fight-or-flight" response. Patients demonstrate abnormal cortisol
levels and basal activity. Studies found that patients with DPD could be distinguished from patients with clinical depression
and posttraumatic stress disorder.
The symptoms are sometimes described by sufferers from neurological organic diseases, such as amyotrophic lateral sclerosis
, Alzheimer's, multiple sclerosis
(MS), neuroborreliosis (Lyme disease
), etc., that directly affect brain tissue.
Onset is typically during the teenage years or early 20s, although some report being depersonalized as long as they can remember, and others report a later onset. The onset can be acute or insidious. With acute onset, some individuals remember the exact time and place of their first experience of depersonalization. This may follow a prolonged period of severe stress, a traumatic event, an episode of another mental illness
, or drug use. Insidious onset may reach back as far as can be remembered, or it may begin with smaller episodes of lesser severity that become gradually stronger. Patients with drug-induced depersonalization do not appear to be a clinically separate group from those with a non-drug precipitant.
, instead of with dissociative disorders as in the DSM-IV-TR.
have been used to treat depersonalization disorder, such as cognitive behavioral therapy, although none of these has established efficacy to date. Clinical pharmacotherapy
research continues to explore a number of possible options, including selective serotonin reuptake inhibitor
s, anticonvulsants, and opioid antagonists.
An open study of cognitive behavior therapy has aimed to help patients reinterpret their symptoms in a nonthreatening way, leading to an improvement on several standardized measures.
In a retrospective report of 117 subjects with DPD, 18 of 35 benzodiazepine
subjects reported slight or definite improvement with benzodiazepines and clonazepam
in particular. Benzodiazepines are not known to reduce dissociative symptoms; however, they do target the often comorbid anxiety and stress experienced by those with DPD and, thus, lead to global improvement. To date, no clinical trials have studied the effectiveness of benzodiazepines.
A series of small studies have suggested a possible role of selective serotonin reuptake inhibitors in treating primary depersonalization disorder. However, a placebo-controlled trial failed to show benefit with fluoxetine
in 54 patients with DPD. SSRI treatment created an overall improvement in participants, but only by reducing anxiety and depression. Clomipramine
is a tricyclic antidepressant
that is helpful with both depression and obsessional disorders. In a study of four subjects treated with clomipramine, two showed clinically significant improvement of DPD. A combination of an SSRI and a benzodiazepine has been proposed to be useful for DPD patients with anxiety. SSRIs have also been used in combination with lamotrigine
, an anticonvulsant.
Naloxone
, an antagonist used primarily for the treatment of opiate overdose, was used in a pilot study in 11 patients with chronic DPD. Of the 11 patients, three experienced complete remission, and seven had marked improvement of depersonalization symptoms. The study reported only immediate treatment results, which makes the efficacy of continued treatment unknown. Naloxone can only be administered intravenously, making long-term treatment difficult. Naltrexone
was used in a preliminary study in 14 individuals with DPD. Participants were treated for 6–10 weeks, at a fairly high average dose of 120 milligrams per day. Three individuals were very much improved, another one was much improved, and on average a 30% decrease in depersonalization symptoms was reported. In another study in borderline personality disorder
, naltrexone doses of 200 milligrams/day were reported to decrease general dissociative symptoms over a two-week period of treatment.
A recently completed study at Columbia University in New York City has shown positive effects from transcranial magnetic stimulation
(TMS) to treat depersonalization disorder. Currently, however, the FDA has not approved TMS to treat DP.
A 2011 study involving lamotrigine
demonstrated efficacy in treating depersonalization disorder in a double-blind placebo-controlled trial. In particular, of the 36 lamotrigine-treated patients, 26 were classified as responders by week 12 versus 6 of the 38 in the placebo-treated participants. The most common and problematic adverse effect in the lamotrigine group was rash (potentially important because of the possibility of Stevens–Johnson syndrome). This trial was the first double-blind, placebo-controlled trial to demonstrate efficacy of any drug for DPD. However, it is not clear how robust the study methodology was. Patients did not receive any antidepressant or anticonvulsant drugs for 2 months before the commencement of the study, however the patients were allowed to take up to 4 mg per day of clonazepam for insomnia, and hydroxyzine of 25 mg 3 times per day during 7 days for the treatment of rash. As noted above, clonazepam
itself is a potential treatment for depersonalization, and hydroxyzine
has been shown to be an effective anxiolytic. Therefore it is unclear whether the benefits in the study are due to the lamotrigine or the clonazepam. The study does not appear to control for the effect of clonazepam or hydroxyzine administration.
Modafinil
used alone has been reported to be effective in a subgroup of individuals with depersonalisation disorder; the subgroup of people with depersonalisation disorder most likely to respond are those who have attentional impairments, under-arousal and hypersomnia
. However, clinical trials have not been conducted. Dr. Evan Torch calls a combination of an SSRI and Modafinil "the hidden pearl that can really help depersonalization disorder".
Depersonalization was first used as a clinical term by Ludovic Dugas in 1898 to refer to "a state in which there is the feeling or sensation that thoughts and acts elude the self and become strange; there is an alienation of personality – in other words a depersonalization". This description refers to personalization as a psychical synthesis of attribution of states to the self.
Early theories of the cause of depersonalization focused on sensory impairment. Maurice Krishaber proposed depersonalization was the result of pathological changes to the body's sensory modalities which lead to experiences of "self-strangeness" and the description of one patient who "feels that he is no longer himself". One of Carl Wernicke's students suggested all sensations were composed of a sensory component and a related muscular sensation that came from the movement itself and served to guide the sensory apparatus to the stimulus. In depersonalized patients these two components were not synchronized, and the myogenic sensation failed to reach consciousness. The sensory hypothesis was challenged by others who suggested that patient complaints were being taken too literally and that some descriptions were metaphors – attempts to describe experiences that are difficult to articulate in words. Pierre Janet
approached the theory by pointing out his patients with clear sensory pathology did not complain of symptoms of unreality, and that those who suffered from depersonalization were normal from a sensory viewpoint.
Psychodynamic theory formed the basis for the conceptualization of dissociation as a defense mechanism.. Within this framework, depersonalization is understood as a defense against a variety of negative feelings, conflicts, or experiences. Sigmund Freud
himself experienced fleeting derealization when visiting the Acropolis in person; having read about it for years and knowing it existed, seeing the real thing was overwhelming and proved difficult for him to perceive it as real.
Freudian theory is the basis for the description of depersonalization as a dissociative reaction, placed within the category of psychoneurotic disorders, in the first two editions of the Diagnostic and Statistical Manual of Mental Disorders
.
, suffers from depersonalization disorder. The screenwriter
for the 2007 film Numb
suffers from depersonalization disorder, as does the film's protagonist played by Matthew Perry
. Norwegian painter Edvard Munch
's famous masterpiece The Scream
may have been inspired by depersonalization disorder. In Glen Hirshberg
's novel The Snowman's Children, main female plot characters throughout the book suffers from a condition that is revealed to be depersonalization disorder. Suzanne Segal
had an episode in her 20s that was diagnosed by several psychologists as depersonalization disorder, though Segal herself interpreted it through the lens of Buddhism
as a spiritual experience.
Depersonalization
Depersonalization is an anomaly of the mechanism by which an individual has self-awareness. It is a feeling of watching oneself act, while having no control over a situation. Sufferers feel they have changed, and the world has become less real, vague, dreamlike, or lacking in significance...
and/or derealization
Derealization
Derealization is an alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one's environment is lacking in spontaneity, emotional coloring and depth. It is a dissociative symptom of many conditions, such as psychiatric and...
. Diagnostic criteria include persistent or recurrent experiences of feeling detached from one's mental processes or body. The symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s include a sense of automaton, going through the motions of life but not experiencing it, feeling as though one is in a movie, loss of conviction with one's identity, feeling as though one is in a dream, feeling a disconnection from one's body; out-of-body experience
Out-of-body experience
An out-of-body experience is an experience that typically involves a sensation of floating outside of one's body and, in some cases, perceiving one's physical body from a place outside one's body ....
, a detachment from one's body, environment and difficulty relating oneself to reality.
Occasional moments of mild depersonalization are normal; strong, severe, persistent, or recurrent feelings are not. A diagnosis of a disorder
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
is made when the dissociation
Dissociation
Dissociation is an altered state of consciousness characterized by partial or complete disruption of the normal integration of a person’s normal conscious or psychological functioning. Dissociation is most commonly experienced as a subjective perception of one's consciousness being detached from...
is persistent and interferes with the social and occupational functions necessary for everyday living. Depersonalization disorder is thought to be largely caused by severe traumatic lifetime events including childhood sexual, physical, and emotional abuse; accidents, war, torture, panic attacks and bad drug experiences. It is unclear whether genetics play a role; however, there are many neurochemical and hormonal changes in individuals suffering with depersonalization disorder.
As the core symptoms of the disorder are thought to protect the victim from negative stimuli, depersonalization disorder can be conceptualized as a defense mechanism. Depersonalization disorder is often comorbid with anxiety disorders, panic disorders, clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
and bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
.
Although depersonalization disorder is an alteration in the subjective experience of reality, it is not related to psychosis
Psychosis
Psychosis means abnormal condition of the mind, and is a generic psychiatric term for a mental state often described as involving a "loss of contact with reality"...
, as sufferers maintain the ability to distinguish between their own internal experiences and the objective reality of the outside world. During episodic and continuous depersonalization, sufferers are able to distinguish between reality and fantasy, and their grasp on reality remains stable at all times.
Symptoms
The core symptom of depersonalization disorder is the subjective experience of unreality, and as such there are no clinical signs. Common descriptions are: watching oneself from a distance; out-of-body experiences; a sense of just going through the motions; feeling as though one is in a dream or movie; not feeling in control of one's speech or physical movements; and feeling detached from one's own thoughts or emotions. Individuals with the disorder commonly describe a feeling as though time is 'passing' them by and they are not in the notion of the present. These experiences which strike at the core of a person's identity and consciousness may cause a person to feel uneasy or anxious.Some of the more common factors that exacerbate dissociative symptoms are negative stimuli, stress, subjective threatening social interaction, and unfamiliar environments. Factors that tend to diminish symptoms are comforting interpersonal interactions, intense physical or emotional stimulation, and relaxation. Some factors are identified as relieving symptom severity such as diet or exercise; alcohol and fatigue are listed by others as worsening symptoms.
Fears of going crazy, brain damage, and losing control are common complaints. Individuals report occupational impairments as they feel they are working below their ability, and interpersonal troubles since they have an emotional disconnection from those they care about. Neuropsychological testing has shown deficits in attention
Attention
Attention is the cognitive process of paying attention to one aspect of the environment while ignoring others. Attention is one of the most intensely studied topics within psychology and cognitive neuroscience....
, short-term memory
Short-term memory
Short-term memory is the capacity for holding a small amount of information in mind in an active, readily available state for a short period of time. The duration of short-term memory is believed to be in the order of seconds. A commonly cited capacity is 7 ± 2 elements...
and spatial-temporal reasoning
Spatial-temporal reasoning
Spatial–temporal reasoning is used in both the fields of psychology and computer science.-Spatial–temporal reasoning in psychology:Spatial-temporal reasoning is the ability to visualize spatial patterns and mentally manipulate them over a time-ordered sequence of spatial transformations.This...
. Depersonalization disorder is associated with cognitive disruptions in early perceptual and attentional processes.
Diagnosis
Diagnosis is based on the self-reported experiences of the person followed by a clinical assessment by a psychiatristPsychiatrist
A psychiatrist is a physician who specializes in the diagnosis and treatment of mental disorders. All psychiatrists are trained in diagnostic evaluation and in psychotherapy...
, social worker, clinical psychologist or other mental health professional
Mental health professional
A mental health professional is a health care practitioner who offers services for the purpose of improving an individual's mental health or to treat mental illness. This broad category includes psychiatrists, clinical psychologists, clinical social workers, psychiatric nurses, mental health...
. Psychiatric assessment includes a psychiatric history
Psychiatric history
A psychiatric history is the result of a medical process where a clinician working in the field of mental health systematically records the content of an interview with a patient...
and some form of mental status examination
Mental status examination
The mental status examination in the USA or mental state examination in the rest of the world, abbreviated MSE, is an important part of the clinical assessment process in psychiatric practice...
. Since some medical and psychiatric conditions mimic the symptoms of DPD, clinicians must differentiate between and rule out the following to establish a precise diagnosis: temporal lobe epilepsy
Temporal lobe epilepsy
Temporal lobe epilepsy a.k.a. Psychomotor epilepsy, is a form of focal epilepsy, a chronic neurological condition characterized by recurrent seizures. Over 40 types of epilepsies are known. They fall into two main categories: partial-onset epilepsies and generalized-onset epilepsies...
, panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
, acute stress disorder, schizophrenia
Schizophrenia
Schizophrenia is a mental disorder characterized by a disintegration of thought processes and of emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganized speech and thinking, and it is accompanied by significant social...
, migraine
Migraine
Migraine is a chronic neurological disorder characterized by moderate to severe headaches, and nausea...
, drug use
Recreational drug use
Recreational drug use is the use of a drug, usually psychoactive, with the intention of creating or enhancing recreational experience. Such use is controversial, however, often being considered to be also drug abuse, and it is often illegal...
, brain tumour or lesion
Lesion
A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...
. No laboratory test for depersonalization disorder currently exists.
The diagnosis of DPD can be made with the use of the following interviews and scales:
The Structured Clinical Interview for DSM-IV
Structured Clinical Interview for DSM-IV
The Structured Clinical Interview for DSM-IV Axis I Disorders is a diagnostic exam used to determine DSM-IV Axis I disorders and Axis II disorders . There are at least 700 published studies in which the SCID was the diagnostic instrument used...
Dissociative Disorders (SCID-D) is widely used, especially in research settings. This interview takes about 30 minutes to 1.5 hours, depending on individual's experiences.
The Dissociative Experiences Scale
Dissociative Experiences Scale
The Dissociative Experiences Scale is a psychological self-assessment questionnaire that measures dissociative symptoms. It contains twenty-eight questions and returns an overall score as well as four sub-scale results. DES is intended to be a screening test, since only 17% of patients with scores...
(DES) is a simple, quick, self-administered questionnaire that has been widely used to measure dissociative symptoms. It has been used in hundreds of dissociative studies, and can detect depersonalization and derealization experiences.
The Dissociative Disorders Interview Schedule (DDIS) is a highly structured interview which makes DSM-IV diagnoses of somatization disorder, borderline personality disorder and major depressive disorder, as well as all the dissociative disorders. It inquires about positive symptoms of schizophrenia, secondary features of dissociative identity disorder
Dissociative identity disorder
Dissociative identity disorder is a psychiatric diagnosis and describes a condition in which a person displays multiple distinct identities , each with its own pattern of perceiving and interacting with the environment....
, extrasensory experiences, substance abuse and other items relevant to the dissociative disorders. The DDIS can usually be administered in 30–45 minutes.
DSM-IV-TR criteria
The diagnostic criteria defined in section 300.6 of the Diagnostic and Statistical Manual of Mental DisordersDiagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
are as follows:
- Longstanding or recurring feelings of being detached from one's mental processes or body, as if one is observing them from the outside or in a dream.
- Reality testing is unimpaired during depersonalization
- Depersonalization causes significant difficulties or distress at work, or social and other important areas of life functioning.
- Depersonalization does not only occur while the individual is experiencing another mental disorder, and is not associated with substance use or a medical illness.
The DSM-IV-TR specifically recognizes three possible additional features of depersonalization disorder:
- DerealizationDerealizationDerealization is an alteration in the perception or experience of the external world so that it seems unreal. Other symptoms include feeling as though one's environment is lacking in spontaneity, emotional coloring and depth. It is a dissociative symptom of many conditions, such as psychiatric and...
, experiencing the external world as strange or unreal. - MacropsiaMacropsiaMacropsia is a neurological condition affecting human visual perception, in which objects within an affected section of the visual field appear larger than normal, causing the subject to feel smaller. Macropsia, along with its opposite condition, micropsia, can be categorized under dysmetropsia...
or micropsiaMicropsiaMicropsia is a condition affecting human visual perception in which objects are perceived to be smaller than they actually are. Micropsia can be caused by either optical distortion of images in the eye or by a neurological dysfunction. The condition of micropsia can be caused by more factors than...
, an alteration in the perception of object size or shape. - A sense that other people seem unfamiliar or mechanical.
Etiology
The exact cause of depersonalization is unknown, although biopsychosocial correlations and triggers have been identified. Childhood interpersonal trauma – emotional abuse in particular – is a significant predictor of a diagnosis. The most common immediate precipitators of the disorder are severe stressStress (medicine)
Stress is a term in psychology and biology, borrowed from physics and engineering and first used in the biological context in the 1930s, which has in more recent decades become commonly used in popular parlance...
; major depressive disorder and panic
Panic
Panic is a sudden sensation of fear which is so strong as to dominate or prevent reason and logical thinking, replacing it with overwhelming feelings of anxiety and frantic agitation consistent with an animalistic fight-or-flight reaction...
; and hallucinogen
Psychedelics, dissociatives and deliriants
This general group of pharmacological agents can be divided into three broad categories: psychedelics, dissociatives, and deliriants. These classes of psychoactive drugs have in common that they can cause subjective changes in perception, thought, emotion and consciousness...
ingestion. People who live in highly individualistic cultures may be more vulnerable to depersonalization, due to threat hypersensitivity and an external locus of control
Locus of control
Locus of control is a theory in personality psychology referring to the extent to which individuals believe that they can control events that affect them. Understanding of the concept was developed by Julian B...
.
One cognitive behavioral conceptualization is that misinterpreting normally transient dissociative symptoms as an indication of severe mental illness or neurological impairment leads to the development of the chronic disorder. This leads to a vicious cycle of heightened anxiety and symptoms of depersonalization and derealization.
Not much is known about the neurobiology of depersonalization disorder; however, there is converging evidence that the prefrontal cortex
Prefrontal cortex
The prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.This brain region has been implicated in planning complex cognitive behaviors, personality expression, decision making and moderating correct social behavior...
may inhibit neural circuits that normally form the substrate of emotional experience. A PET scan
Positron emission tomography
Positron emission tomography is nuclear medicine imaging technique that produces a three-dimensional image or picture of functional processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide , which is introduced into the body on a...
found functional abnormalities in the visual
Visual cortex
The visual cortex of the brain is the part of the cerebral cortex responsible for processing visual information. It is located in the occipital lobe, in the back of the brain....
, auditory, and somatosensory cortex, as well as in areas responsible for an integrated body schema. In an fMRI study of DPD patients, emotionally aversive scenes activated the right ventral prefrontal cortex
Prefrontal cortex
The prefrontal cortex is the anterior part of the frontal lobes of the brain, lying in front of the motor and premotor areas.This brain region has been implicated in planning complex cognitive behaviors, personality expression, decision making and moderating correct social behavior...
. Participants demonstrated a reduced neural response in emotion-sensitive regions, as well as an increased response in regions associated with emotional regulation. In a similar test of emotional memory
Memory
In psychology, memory is an organism's ability to store, retain, and recall information and experiences. Traditional studies of memory began in the fields of philosophy, including techniques of artificially enhancing memory....
, depersonalization disorder patients did not process emotionally salient material in the same way as did healthy controls. In a test of skin conductance responses to unpleasant stimuli, the subjects showed a selective inhibitory mechanism on emotional processing.
Depersonalization disorder may be associated with dysregulation of the hypothalamic-pituitary-adrenal axis
Hypothalamic-pituitary-adrenal axis
The hypothalamic-pituitary-adrenal axis , also known as thelimbic-hypothalamic-pituitary-adrenal axis and, occasionally, as the hypothalamic-pituitary-adrenal-gonadotropic axis, is a complex set of direct influences and feedback interactions among the hypothalamus, the pituitary gland ,...
, the area of the brain involved in the "fight-or-flight" response. Patients demonstrate abnormal cortisol
Cortisol
Cortisol is a steroid hormone, more specifically a glucocorticoid, produced by the adrenal gland. It is released in response to stress and a low level of blood glucocorticoids. Its primary functions are to increase blood sugar through gluconeogenesis; suppress the immune system; and aid in fat,...
levels and basal activity. Studies found that patients with DPD could be distinguished from patients with clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
and posttraumatic stress disorder.
The symptoms are sometimes described by sufferers from neurological organic diseases, such as amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis
Amyotrophic lateral sclerosis , also referred to as Lou Gehrig's disease, is a form of motor neuron disease caused by the degeneration of upper and lower neurons, located in the ventral horn of the spinal cord and the cortical neurons that provide their efferent input...
, Alzheimer's, multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...
(MS), neuroborreliosis (Lyme disease
Lyme disease
Lyme disease, or Lyme borreliosis, is an emerging infectious disease caused by at least three species of bacteria belonging to the genus Borrelia. Borrelia burgdorferi sensu stricto is the main cause of Lyme disease in the United States, whereas Borrelia afzelii and Borrelia garinii cause most...
), etc., that directly affect brain tissue.
Epidemiology
Men and women are diagnosed in equal numbers with depersonalization disorder. A 1991 study on a sample from Winnipeg, Manitoba estimated the prevalence of depersonalization disorder at 2.4% of the population. A 2008 review of several studies estimated the prevalence between 0.8% and 2%. This disorder is episodic in about one-third of individuals, with each episode lasting from hours to months at a time. Depersonalization can begin episodically, and later become continuous at constant or varying intensity.Onset is typically during the teenage years or early 20s, although some report being depersonalized as long as they can remember, and others report a later onset. The onset can be acute or insidious. With acute onset, some individuals remember the exact time and place of their first experience of depersonalization. This may follow a prolonged period of severe stress, a traumatic event, an episode of another mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
, or drug use. Insidious onset may reach back as far as can be remembered, or it may begin with smaller episodes of lesser severity that become gradually stronger. Patients with drug-induced depersonalization do not appear to be a clinically separate group from those with a non-drug precipitant.
Relation to psychiatric disorders
Depersonalization exists as both a primary and secondary phenomenon, although making a clinical distinction appears easy but is not absolute. The most common comorbid disorders are depression and anxiety, although cases of depersonalization disorder without symptoms of either do exist. Comorbid obsessive and compulsive behaviours may exist as attempts to deal with depersonalization, such as checking whether symptoms have changed and avoiding behavioural and cognitive factors that exacerbate symptoms. Researchers at the Institute of Psychiatry in London, England suggest depersonalization disorder be placed with anxiety and mood disorders, as in the ICD-10ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
, instead of with dissociative disorders as in the DSM-IV-TR.
Treatment
To date, no treatment recommendations or guidelines for depersonalization disorder have been established, and it remains largely resistant to treatment. A variety of psychotherapeutic techniquesPsychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
have been used to treat depersonalization disorder, such as cognitive behavioral therapy, although none of these has established efficacy to date. Clinical pharmacotherapy
Pharmacotherapy
Pharmacotherapy is the treatment of disease through the administration of drugs. As such, it is considered part of the larger category of therapy....
research continues to explore a number of possible options, including selective serotonin reuptake inhibitor
Selective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
s, anticonvulsants, and opioid antagonists.
An open study of cognitive behavior therapy has aimed to help patients reinterpret their symptoms in a nonthreatening way, leading to an improvement on several standardized measures.
In a retrospective report of 117 subjects with DPD, 18 of 35 benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
subjects reported slight or definite improvement with benzodiazepines and clonazepam
Clonazepam
Clonazepamis a benzodiazepine drug having anxiolytic, anticonvulsant, muscle relaxant, and hypnotic properties. It is marketed by Roche under the trade name Klonopin in the United States and Rivotril in Australia, Brazil, Canada and Europe...
in particular. Benzodiazepines are not known to reduce dissociative symptoms; however, they do target the often comorbid anxiety and stress experienced by those with DPD and, thus, lead to global improvement. To date, no clinical trials have studied the effectiveness of benzodiazepines.
A series of small studies have suggested a possible role of selective serotonin reuptake inhibitors in treating primary depersonalization disorder. However, a placebo-controlled trial failed to show benefit with fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
in 54 patients with DPD. SSRI treatment created an overall improvement in participants, but only by reducing anxiety and depression. Clomipramine
Clomipramine
Clomipramine is a tricyclic antidepressant . It was developed in the 1960s by the Swiss drug manufacturer Geigy and has been in clinical use worldwide ever since.- Indications :...
is a tricyclic antidepressant
Tricyclic antidepressant
Tricyclic antidepressants are heterocyclic chemical compounds used primarily as antidepressants. The TCAs were first discovered in the early 1950s and were subsequently introduced later in the decade; they are named after their chemical structure, which contains three rings of atoms...
that is helpful with both depression and obsessional disorders. In a study of four subjects treated with clomipramine, two showed clinically significant improvement of DPD. A combination of an SSRI and a benzodiazepine has been proposed to be useful for DPD patients with anxiety. SSRIs have also been used in combination with lamotrigine
Lamotrigine
Lamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used as an adjunct in treating depression, though this is considered off-label usage...
, an anticonvulsant.
Naloxone
Naloxone
Naloxone is an opioid antagonist drug developed by Sankyo in the 1960s. Naloxone is a drug used to counter the effects of opiate overdose, for example heroin or morphine overdose. Naloxone is specifically used to counteract life-threatening depression of the central nervous system and respiratory...
, an antagonist used primarily for the treatment of opiate overdose, was used in a pilot study in 11 patients with chronic DPD. Of the 11 patients, three experienced complete remission, and seven had marked improvement of depersonalization symptoms. The study reported only immediate treatment results, which makes the efficacy of continued treatment unknown. Naloxone can only be administered intravenously, making long-term treatment difficult. Naltrexone
Naltrexone
Naltrexone is an opioid receptor antagonist used primarily in the management of alcohol dependence and opioid dependence. It is marketed in generic form as its hydrochloride salt, naltrexone hydrochloride, and marketed under the trade names Revia and Depade...
was used in a preliminary study in 14 individuals with DPD. Participants were treated for 6–10 weeks, at a fairly high average dose of 120 milligrams per day. Three individuals were very much improved, another one was much improved, and on average a 30% decrease in depersonalization symptoms was reported. In another study in borderline personality disorder
Borderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
, naltrexone doses of 200 milligrams/day were reported to decrease general dissociative symptoms over a two-week period of treatment.
A recently completed study at Columbia University in New York City has shown positive effects from transcranial magnetic stimulation
Transcranial magnetic stimulation
Transcranial magnetic stimulation is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain...
(TMS) to treat depersonalization disorder. Currently, however, the FDA has not approved TMS to treat DP.
A 2011 study involving lamotrigine
Lamotrigine
Lamotrigine, marketed in the US and most of Europe as Lamictal by GlaxoSmithKline, is an anticonvulsant drug used in the treatment of epilepsy and bipolar disorder. It is also used as an adjunct in treating depression, though this is considered off-label usage...
demonstrated efficacy in treating depersonalization disorder in a double-blind placebo-controlled trial. In particular, of the 36 lamotrigine-treated patients, 26 were classified as responders by week 12 versus 6 of the 38 in the placebo-treated participants. The most common and problematic adverse effect in the lamotrigine group was rash (potentially important because of the possibility of Stevens–Johnson syndrome). This trial was the first double-blind, placebo-controlled trial to demonstrate efficacy of any drug for DPD. However, it is not clear how robust the study methodology was. Patients did not receive any antidepressant or anticonvulsant drugs for 2 months before the commencement of the study, however the patients were allowed to take up to 4 mg per day of clonazepam for insomnia, and hydroxyzine of 25 mg 3 times per day during 7 days for the treatment of rash. As noted above, clonazepam
Clonazepam
Clonazepamis a benzodiazepine drug having anxiolytic, anticonvulsant, muscle relaxant, and hypnotic properties. It is marketed by Roche under the trade name Klonopin in the United States and Rivotril in Australia, Brazil, Canada and Europe...
itself is a potential treatment for depersonalization, and hydroxyzine
Hydroxyzine
Hydroxyzine is a first-generation antihistamine of the diphenylmethane and piperazine classes. It was first synthesized by Union Chimique Belge in 1956 and was marketed by Pfizer in the United States later the same year, and is still in widespread use today....
has been shown to be an effective anxiolytic. Therefore it is unclear whether the benefits in the study are due to the lamotrigine or the clonazepam. The study does not appear to control for the effect of clonazepam or hydroxyzine administration.
Modafinil
Modafinil
Modafinil is an analeptic drug manufactured by Cephalon, and is approved by the U.S. Food and Drug Administration for the treatment of narcolepsy, shift work sleep disorder, and excessive daytime sleepiness associated with obstructive sleep apnea...
used alone has been reported to be effective in a subgroup of individuals with depersonalisation disorder; the subgroup of people with depersonalisation disorder most likely to respond are those who have attentional impairments, under-arousal and hypersomnia
Hypersomnia
Hypersomnia is a disorder characterized by excessive amounts of sleepiness.There are two main categories of hypersomnia: primary hypersomnia and recurrent hypersomnia...
. However, clinical trials have not been conducted. Dr. Evan Torch calls a combination of an SSRI and Modafinil "the hidden pearl that can really help depersonalization disorder".
History
The word depersonalization itself was first used by Henri Frédéric Amiel in The Journal Intime. The July 8, 1880 entry reads:
"I find myself regarding existence as though from beyond the tomb, from another world; all is strange to me; I am, as it were, outside my own body and individuality; I am depersonalized, detached, cut adrift. Is this madness?"
Depersonalization was first used as a clinical term by Ludovic Dugas in 1898 to refer to "a state in which there is the feeling or sensation that thoughts and acts elude the self and become strange; there is an alienation of personality – in other words a depersonalization". This description refers to personalization as a psychical synthesis of attribution of states to the self.
Early theories of the cause of depersonalization focused on sensory impairment. Maurice Krishaber proposed depersonalization was the result of pathological changes to the body's sensory modalities which lead to experiences of "self-strangeness" and the description of one patient who "feels that he is no longer himself". One of Carl Wernicke's students suggested all sensations were composed of a sensory component and a related muscular sensation that came from the movement itself and served to guide the sensory apparatus to the stimulus. In depersonalized patients these two components were not synchronized, and the myogenic sensation failed to reach consciousness. The sensory hypothesis was challenged by others who suggested that patient complaints were being taken too literally and that some descriptions were metaphors – attempts to describe experiences that are difficult to articulate in words. Pierre Janet
Pierre Janet
Pierre Marie Félix Janet was a pioneering French psychologist, philosopher and psychotherapist in the field of dissociation and traumatic memory....
approached the theory by pointing out his patients with clear sensory pathology did not complain of symptoms of unreality, and that those who suffered from depersonalization were normal from a sensory viewpoint.
Psychodynamic theory formed the basis for the conceptualization of dissociation as a defense mechanism.. Within this framework, depersonalization is understood as a defense against a variety of negative feelings, conflicts, or experiences. Sigmund Freud
Sigmund Freud
Sigmund Freud , born Sigismund Schlomo Freud , was an Austrian neurologist who founded the discipline of psychoanalysis...
himself experienced fleeting derealization when visiting the Acropolis in person; having read about it for years and knowing it existed, seeing the real thing was overwhelming and proved difficult for him to perceive it as real.
Freudian theory is the basis for the description of depersonalization as a dissociative reaction, placed within the category of psychoneurotic disorders, in the first two editions of the Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
.
Depersonalization and Meditation
Some studies have concluded that meditation can cause depersonalization, although in some cases there is no social or occupational impairmentSociety and culture
Depersonalization disorder has appeared in a variety of media. The director of the autobiographical documentary Tarnation, Jonathan CaouetteJonathan Caouette
Jonathan Caouette is an American film director, writer, editor and actor. Caouette is the director and editor of Tarnation , an autobiographical documentary, and director of All Tomorrow's Parties about a cult music festival.-Films:...
, suffers from depersonalization disorder. The screenwriter
Screenwriter
Screenwriters or scriptwriters or scenario writers are people who write/create the short or feature-length screenplays from which mass media such as films, television programs, Comics or video games are based.-Profession:...
for the 2007 film Numb
Numb (film)
Numb is a 2007 American drama film written and directed by Harris Goldberg. According to an interview with Goldberg on a bonus feature of the DVD release, he was inspired to write the screenplay by his own experience battling depersonalization disorder and clinical depression.-Plot:When modestly...
suffers from depersonalization disorder, as does the film's protagonist played by Matthew Perry
Matthew Perry (actor)
Matthew Langford Perry is a Canadian-American actor and comedian, best known for his Emmy-nominated role as Chandler Bing on the popular, long-running NBC television sitcom Friends...
. Norwegian painter Edvard Munch
Edvard Munch
Edvard Munch was a Norwegian Symbolist painter, printmaker and an important forerunner of expressionist art. His best-known composition, The Scream, is part of a series The Frieze of Life, in which Munch explored the themes of love, fear, death, melancholia, and anxiety.- Childhood :Edvard Munch...
's famous masterpiece The Scream
The Scream
Scream is the title of Expressionist paintings and prints in a series by Norwegian artist Edvard Munch, showing an agonized figure against a blood red sky...
may have been inspired by depersonalization disorder. In Glen Hirshberg
Glen Hirshberg
Glen Hirshberg is an American author of horror fiction. His works include the short story collection The Two Sams, published in 2003 by Carroll & Graf; the collection American Morons, published in 2006 by Earthling Publications; and the novel The Snowman's Children, published by Carroll & Graf in...
's novel The Snowman's Children, main female plot characters throughout the book suffers from a condition that is revealed to be depersonalization disorder. Suzanne Segal
Suzanne Segal
Suzanne Segal was a New Age writer and teacher about spiritual enlightenment, known for her sudden experience of depersonalization which she wrote about in her book Collision With the Infinite: A Life Beyond the Personal Self....
had an episode in her 20s that was diagnosed by several psychologists as depersonalization disorder, though Segal herself interpreted it through the lens of Buddhism
Buddhism
Buddhism is a religion and philosophy encompassing a variety of traditions, beliefs and practices, largely based on teachings attributed to Siddhartha Gautama, commonly known as the Buddha . The Buddha lived and taught in the northeastern Indian subcontinent some time between the 6th and 4th...
as a spiritual experience.
See also
- Sluggish cognitive tempoSluggish cognitive tempoSluggish Cognitive Tempo is an unformalized descriptive term which is used to better identify what appears to be a homogeneous sub-subgroup within the formal subgroup "ADHD predominantly inattentive"...
- ADHD predominantly inattentiveADHD predominantly inattentiveADHD predominantly inattentive is one of the three subtypes of Attention-deficit hyperactivity disorder . While ADHD-PI is sometimes still called "attention deficit disorder" by the general public, these older terms were formally changed in 1994 in the new Diagnostic and Statistical Manual of...
- Daphne SimeonDaphne SimeonDaphne Simeon M.D. is an American psychiatrist, best known for her research on depersonalization disorder.-Education:Simeon is a graduate of Columbia University's medical school, psychiatry residency and fellowship program, and psychoanalytic institute. Simeon now works at Beth Israel Medical...
- Frederick T. Melges
External links
- Depersonalization Research Abstracts – List of research articles concerning depersonalization disorder.