196 Depersonalization Disorder (300.6)

Derealization or depersonalization is characterized by feelings that the objects of the external environment are changing shape and size, or that people are automated and inhuman, and each of them features detachment as a major defense. Depersonalization disorder usually begins in adolescence; typically, patients have continuous symptoms. Onset can be sudden or gradual. There is an estimated 2.4% of the general population that meets the diagnostic criteria for this disorder. However, the prevalence rate is questioned by many clinicians may be lower. This disorder is frequently coexists with mood, anxiety, and psychotic disorders. (American Psychiatric Association, 2000)

Mental Status

• Patients present alert and disoriented in some spheres.
• Both relatedness and eye contact are limited.
• Patient may appear preoccupied and irritable.
• A distressed facial expression with constricted affect is characteristic.
• Reasoning, judgment, and insight are fair to limited.

The DSM-IV-TR criteria according to the American Psychiatric Association (2000) includes the following:

• A. “Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body (e.g., feeling like one is in a dream)” (p. 532).
• B. “During the depersonalization experience, reality testing remains intact” (p. 532).
• C. “The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (p. 532).
• D. “The depersonalization experience does not occur exclusively during the course of another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy)” (p. 532).

Associated features

Associated features may include anxiety or depression. Sometimes, individuals have a hard time with sense of time and may have somatic manifestations. Comorbidity can include Obsessive-compulsive, Dysthymic, or Major Depressive disorders. Individuals with Depersonalization disorder may have personality disorders as well. Individuals with Depersonalization Disorder often have difficulty describing their symptoms and may fear that they will be seen as “crazy.” They may also experience derealization in the sense that the external world is unreal, and they may perceive an alteration in the size or shape of objects. People may seem unfamiliar or mechanical. Other features could include obsessive rumination, somatic concerns, a disturbance in the sense of time, and Hypochondriasis. (American Psychiatric Association, 2000)

Child vs. Adult presentation

The disorder is more likely to occur in late adolescence to adulthood.

Gender and cultural differences in presentation

From various studies, equal numbers of men and women are diagnosed. Individuals from individualistic societies are more likely to suffer from the disorder (see Etiology). Some cultures make use of meditative and trance practices which result in experiences of depersonalization and derealization.

Epidemiology

“Although much of the general population experiences a depersonalization experience (whether caused by a traumatic experience or danger, or a drug induced experience), only about 2.4% of the population has been diagnosed with depersonalization disorder. Onset is typical during the teenage years and early 20s, though some report earlier or later onset (the mean age is around 16 years). There can be an acute or insidious onset. When acute, some individuals will remember the time and place of their first depersonalization experience. Insidious onset may reach as far back as one remembers, or it may begin with smaller episodes that increase in severity over time. Duration of episodes may be very brief or persistent. Depersonalization following a life-threatening situation usually develops suddenly upon exposure to teh trauma. The course is usually chronic and may fluctuate in intensity, but it is sometimes episodic. Actual or perceived stressful events most often exacerbate the symptoms.” (American Psychiatric Association, 2000)

Etiology

Similar to the other dissociative disorders, scientists link severe childhood abuse to depersonalization disorders. Brain imaging, including pet scans, show sensory cortex abnormalities. Positron emission tomography scans used to assess brain glucose metabolism show abnormalities in the sensory cortex including the temporal, occipital, and parietal lobes. The sensory cortex controls the senses and perception of an individual’s body in space. Lower levels of nerve cell responses in the area of the brain that controls emotion may correlate to the emotional detachment that individual’s feel during an episode of depersonalization. Western cultures where individuals live in a more individualistic society, may be more likely to suffer from a depersonalization disorder. Individualism is stressed in most Western cultures and may have an effect on an individual’s sense of self. (American Psychiatric Association, 2000)

Empirically supported treatments

• “Treatment recommendations and guidelines for depersonalisation disorder have not been established. There are few studies assessing the use of pharmacotherapy in this disorder. Medication options that have been reported include clomipramine, fluoxetine, lamotrigine and opioid antagonists. However, it does not appear that any of these agents have a potent anti-dissociative effect. A variety of psychotherapeutic techniques has been used to treat depersonalisation disorder (including trauma-focused therapy and cognitive-behavioural techniques), although again none of these have established efficacy to date. Overall, novel therapeutic approaches are clearly needed to help individuals experiencing this refractory disorder.” (Simeon, 2004)
• Treatment for this disorder is more about treating the symptoms of the disorder or stresses associated disorder, more than the disorder itself. Treatments for the stresses include Psychotherapy, Cognitive Therapy, medications, Family therapy, Creative Therapies, and Clinical hypnosis.
• Psychotherapy
  • A type of counseling and is the primary treatment for dissociative disorders.
• Cognitive Therapy
  • Therapy that focuses on changing the thinking pattern and the resulting behaviors.
• Family Therapy
  • Therapy for the family to help teach them about the causes of the disorder. This therapy can also help the family recognize and recurrence of symptoms.
• Creative Therapy
  • Forms of therapy that helps the patient express and explore their thoughts and feelings in a creative and safe manner.
• Medications
  • Antidepressants and anti-anxiety medications are used for the depression and the anxiety often felt by people with this disorder.

A film based on a person suffering from depersonalization disorder: