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Clinical and Research News
Depersonalization Again Finds Psychiatric Spotlight
Psychiatric News
Volume 38 Number 16 page 18-30
Anchor for JumpAnchor for Jump"This sounds mad, but when I look in the mirror, I see someone other than myself," 28-year-old Robert said. "Logically that cannot be the case, I know, but that is how it feels."

"I feel like I’m listening to someone else talking," 30-year-old Chelsea explained. "I know that it’s not another person’s voice, but it feels like it."

Depersonalization—viewing yourself with detachment—is not a new phenomenon. It was described in the 19th century, but for years it was neglected by psychiatric science, and even today, many clinical psychiatrists know little about it. Nonetheless, during the past decade or so a few American and British researchers have been trying to learn more about the phenomenon, and they are coming up with some interesting insights into it.

The phenomenon of depersonalization is probably not as rare as many clinical psychiatrists think. Anthony David, M.D., a professor of cognitive neuropsychiatry at the Institute of Psychiatry in London, and colleagues managed to amass some 200 depersonalization cases over a four-year period. The cases came not just from England, but from other parts of Europe, North America, Australia, and the Far East.

"This is the largest cohort of people with depersonalization described to date," they reported in the May British Journal of Psychiatry.

Depersonalization disorder appears to be a distinct psychiatric disorder, not just a part of anxiety, depression, borderline personality, or some other psychiatric condition, Daphne Simeon, M.D., an associate professor of psychiatry at Mount Sinai School of Medicine in New York City and another of the few researchers scrutinizing depersonalization, told Psychiatric News.

"One of my major contributions during the past decade," she said, "has been descriptively documenting that the disorder really exists, making the point that it is a distinct condition."

A good part of her documentation is in press with the Journal of Clinical Psychiatry and is based on 117 cases.

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A number of factors appear to be capable of setting the stage for depersonalization, or at least contributing to it. For example, genes may have some influence. In their study of 200 patients, David and his group found that some 10 percent had first- or second-degree relatives who had also experienced depersonalization.

Childhood trauma looms even larger as a culprit. Simeon and her coworkers compared the childhoods of 49 subjects with depersonalization disorder with those of 26 healthy comparison subjects. As they reported in the July 2001 American Journal of Psychiatry, childhood interpersonal trauma—such as experiencing physical neglect, physical abuse, sexual abuse, emotional abuse, or witnessing violence—was highly predictive of depersonalization, but emotional abuse per se was especially so.

Depression and anxiety may play a role. Half of the 200 depersonalization-disorder subjects on whom David and colleagues had collected data had a diagnosis of one or more psychiatric disorders as well. The most common diagnoses were depression, anxiety, or both. What’s more, changes in autonomic nervous system functioning have been found not just in persons with anxiety disorders but in those with depersonalization disorder, reinforcing the suspicion that there may be some nervous system interplay between anxiety and depersonalization. This finding comes from researchers at the Institute of Psychiatry in London and appeared in the September 2002 Archives of General Psychiatry.

Migraine headaches may be implicated too. Almost a third of the subjects studied by David and his team experienced migraines, and a number of them believed that their headaches and depersonalization were related. In contrast, Simeon and her colleagues found that the prevalence of migraines in their depersonalization subjects was about the same as in the general population, implying that migraines are not involved in depersonalization.

Finally, substance abuse may be a trigger. Forty of the 200 subjects studied by David and his colleagues first experienced depersonalization after using illicit drugs, and 28 first experienced it after using alcohol. The drugs most likely to induce depersonalization are marijuana, hallucinogens, ecstasy, and ketamine.

While depersonalization usually strikes first at a young age, the two groups of researchers differ on what that age is: According to Simeon and coworkers, it is around 16; according to David and colleagues, it is around 23. But even in the cohort David and his team studied, a third were younger than 23 at age of onset, and those who had the condition earlier also tended to report more severe symptoms.

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What is depersonalization really? The phenomenon, of course, is best known as a feeling of being detached from one’s body. But it can also make individuals feel removed from their emotions, cases scrutinized by David and company reveal. Take a 54-year-old lawyer, Sandra, who has experienced depersonalization for 30 years: "I feel nothing—no anxiety, no depression, no pain, no happiness—I never have. It drives my husband mad when I talk about it."

The condition also appears capable of triggering auditory hallucinations, at least in those persons who succumb to depersonalization as young as at 16 years of age, David and coworkers have found. Fortunately, though, it looks as though those individuals who experience depersonalization and auditory hallucinations will not go on to develop a psychotic illness.

Nonetheless, depersonalization tends to run a chronic, unremitting course, both groups of researchers have found. Not surprisingly, it can cause those who experience it extreme distress. Several of the depersonalization subjects whom David and his team studied expressed their anguish in these ways: "These feelings are unbearable," "I’m unreal and truly alone," and "I feel so depressed, I can’t go on living this way."

Yet going on living this way is what most patients with depersonalization will probably have to do—for the near future anyway—since no effective treatment has yet been found. For instance, there have been two controlled drug trials conducted on depersonalization subjects, and both have produced negative results. In the first, Simeon and her coworkers compared fluoxetine with placebo in 54 subjects. Although fluoxetine made subjects with anxiety or depression feel better, it did not counter their depersonalization. In the other study, David and coworkers compared the glutamate antagonist lamotrigine with placebo in a double-blind, crossover protocol conducted on nine subjects. Initially lamotrigine looked promising, but ultimately was not effective.

Nonetheless, Simeon and her group are now attempting to see whether naltrexone might help depersonalization subjects since there are some anecdotal reports of its reducing dissociation in some patients with borderline personality disorder. What’s more, David and coworkers have designed a cognitive behavioral therapy expressly for persons with depersonalization disorder, and preliminary results with the therapy look promising. ▪

Anchor for JumpAnchor for Jump"This sounds mad, but when I look in the mirror, I see someone other than myself," 28-year-old Robert said. "Logically that cannot be the case, I know, but that is how it feels."

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