Depersonalization

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Individuals who experience depersonalization feel divorced from their own personal self as not belonging to the same identity. Depersonalization.jpg
Individuals who experience depersonalization feel divorced from their own personal self as not belonging to the same identity.

Depersonalization is a dissociative phenomenon characterized by a subjective feeling of detachment from oneself, manifesting as a sense of disconnection from one's thoughts, emotions, sensations, or actions, and often accompanied by a feeling of observing oneself from an external perspective. [1] [2] Subjects perceive that the world has become vague, dreamlike, surreal, or strange, leading to a diminished sense of individuality or identity. Sufferers often feel as though they are observing the world from a distance, [3] as if separated by a barrier "behind glass". [2] They maintain insight into the subjective nature of their experience, recognizing that it pertains to their own perception rather than altering objective reality. This distinction between subjective experience and objective reality distinguishes depersonalization from delusions, where individuals firmly believe in false perceptions as genuine truths. Depersonalization is also distinct from derealization, which involves a sense of detachment from the external world rather than from oneself.

Contents

Depersonalization/derealization disorder refers to chronic depersonalization, classified as a dissociative disorder [4] in both the DSM-4 and the DSM-5, which underscores its association with disruptions in consciousness, memory, identity, or perception. [5] This classification is based on the findings that depersonalization and derealization are prevalent in other dissociative disorders including dissociative identity disorder. [6]

Though degrees of depersonalization can happen to anyone who is subject to temporary anxiety or stress, chronic depersonalization is more related to individuals who have experienced a severe trauma or prolonged stress/anxiety. Depersonalization-derealization is the single most important symptom in the spectrum of dissociative disorders, including dissociative identity disorder and "dissociative disorder not otherwise specified" (DD-NOS). It is also a prominent symptom in some other non-dissociative disorders, such as anxiety disorders, clinical depression, bipolar disorder, schizophrenia, [7] schizoid personality disorder, hypothyroidism or endocrine disorders, [8] schizotypal personality disorder, borderline personality disorder, obsessive–compulsive disorder, migraines, and sleep deprivation; it can also be a symptom of some types of neurological seizure, and it has been suggested that there could be common aetiology between depersonalization symptoms and panic disorder, on the basis of their high co-occurrence rates. [2]

In social psychology, and in particular self-categorization theory, the term depersonalization has a different meaning and refers to "the stereotypical perception of the self as an example of some defining social category". [9]

Description

Individuals who experience depersonalization feel divorced from their own personal self by sensing their body sensations, feelings, emotions, behaviors, etc. as not belonging to the same person or identity. [10] Often a person who has experienced depersonalization claims that things seem unreal or hazy. Also, a recognition of a self breaks down (hence the name). Depersonalization can result in very high anxiety levels, which further increase these perceptions. [11]

Depersonalization is a subjective experience of unreality in one's self, while derealization is unreality of the outside world. Although most authors currently regard depersonalization (personal/self) and derealization (reality/surroundings) as independent constructs, many do not want to separate derealization from depersonalization. [12]

Epidemiology

Despite the distressing nature of symptoms, estimating the prevalence rates of depersonalization is challenging due to inconsistent definitions and variable timeframes. [2]

Depersonalization is a symptom of anxiety disorders, such as panic disorder. [13] [14] It can also accompany sleep deprivation (often occurring when experiencing jet lag), migraine, epilepsy (especially temporal lobe epilepsy, [15] complex-partial seizure, both as part of the aura and during the seizure [16] ), obsessive-compulsive disorder, severe stress or trauma, anxiety, the use of recreational drugs [17] —especially cannabis, hallucinogens, ketamine, and MDMA, certain types of meditation, deep hypnosis, extended mirror or crystal gazing, sensory deprivation, and mild-to-moderate head injury with little or full loss of consciousness (less likely if unconscious for more than 30 minutes). Interoceptive exposure is a non-pharmacological method that can be used to induce depersonalization. [18] [8]

In the general population, transient depersonalization and derealization are common, having a lifetime prevalence between 26 and 74%. [2] A random community-based survey of 1,000 adults in the US rural south found a 1-year depersonalization prevalence rate at 19%. Standardized diagnostic interviews have reported prevalence rates of 1.2% to 1.7% over one month in UK samples, and a rate of 2.4% in a single-point Canadian sample. [2] In clinical populations, prevalence rates range from 1% to 16%, with varying rates in specific psychiatric disorders such as panic disorder and unipolar depression. [2] Co-occurrence between depersonalization/derealization and panic disorder is common, suggesting a possible common etiology. Co-morbidity with other disorders does not influence symptom severity consistently. [14]

Depersonalization occurs 2-4 times more in women than in men, [19] but depersonalization/derealization disorder is diagnosed approximately equally across men and women, with symptoms typically emerging around the age of 16. [14]

A similar and overlapping concept called ipseity disturbance (ipse is Latin for "self" or "itself" [20] ) may be part of the core process of schizophrenia spectrum disorders. However, specific to the schizophrenia spectrum seems to be "a dislocation of first-person perspective such that self and other or self and world may seem to be non-distinguishable, or in which the individual self or field of consciousness takes on an inordinate significance in relation to the objective or intersubjective world" (emphasis in original). [7]

For the purposes of evaluation and measurement depersonalization can be conceived of as a construct and scales are now available to map its dimensions in time and space.[ clarification needed ] [21] A study of undergraduate students found that individuals high on the depersonalization/derealization subscale of the Dissociative Experiences Scale exhibited a more pronounced cortisol response in stress. Individuals high on the absorption subscale, which measures a subject's experiences of concentration to the exclusion of awareness of other events, showed weaker cortisol responses. [22]

Causes

Depersonalization can arise from a variety of factors, of both a psychological and physiological nature. Common immediate precipitants include instances of severe stress, depressive episodes, panic attacks, and the consumption of psychoactive substances such as marijuana and hallucinogens. Additionally, there exists a correlation between frequent depersonalization and childhood interpersonal trauma, particularly cases involving emotional maltreatment. [14]

A case-control study conducted at a specialized depersonalization clinic included 164 individuals with chronic depersonalization symptoms, of which 40 linked their symptoms to illicit drug use. Phenomenological similarity between drug-induced and non-drug groups was observed, and comparison with matched controls further supported the lack of distinction. The severity of clinical depersonalization symptoms remains consistent regardless of whether they are triggered by illicit drugs or psychological factors. [23]

Pharmacological

Depersonalization has been described by some as a desirable state, particularly by those that have experienced it under the influence of mood-altering recreational drugs. It is an effect of dissociatives and psychedelics, as well as a possible side effect of caffeine, alcohol, amphetamine, cannabis, and antidepressants. [24] [25] [26] [27] [28] It is a classic withdrawal symptom from many drugs. [29] [30] [31] [32]

Benzodiazepine dependence, which can occur with long-term use of benzodiazepines, can induce chronic depersonalization symptomatology and perceptual disturbances in some people, even in those who are taking a stable daily dosage, and it can also become a protracted feature of the benzodiazepine withdrawal syndrome. [33] [34]

Lieutenant Colonel Dave Grossman, in his book On Killing , suggests that military training artificially creates depersonalization in soldiers, suppressing empathy and making it easier for them to kill other human beings. [35]

Graham Reed (1974) claimed that depersonalization occurs in relation to the experience of falling in love. [36]

Situational

Experiences of depersonalization/derealization occur on a continuum, ranging from momentary episodes in healthy individuals under conditions of stress, fatigue, or drug use, to severe and chronic disorders that can persist for decades. [2] Several studies found that up to 66% of individuals in life-threatening accidents report at least transient depersonalization during or immediately after the accidents. [16]

Several studies, but not all, found age to be a significant factor: adolescents and young adults in the normal population reported the highest rate. In a study, 46% of college students reported at least one significant episode in the previous year. In another study, 20% of patients with minor head injury experience significant depersonalization and derealization.

In general infantry and special forces soldiers, measures of depersonalization and derealization increased significantly after training that includes experiences of uncontrollable stress, semi-starvation, sleep deprivation, as well as lack of control over hygiene, movement, communications, and social interactions. [16]

Psychobiological mechanisms

Proximate Mechanism

Depersonalization involves disruptions in the integration of interoceptive and exteroceptive signals, particularly in response to acute anxiety or trauma-related events. Studies spanning from 1992 to 2020 have highlighted abnormalities in primary somatosensory cortex processing and insula activity as contributing factors to depersonalization experiences. [5] Additionally, abnormal EEG activities, notably in the theta band, suggest potential biomarkers for emotion processing, attention, and working memory, though specific oscillatory signatures associated with depersonalization are yet to be determined. [5] Reduced brain activities in sensory processing units, along with alterations in visceral signal processing regions, are observed, particularly in the early stages of information processing. [5] [14]

Furthermore, vestibular signal processing, crucial for balance and spatial orientation, is increasingly recognized as a factor contributing to feelings of disembodiment during depersonalization experiences. Research suggests that abnormal activity in the left hemisphere may play a role, although abnormalities in right hemisphere brain activity, responsible for self-awareness and emotion processing, may also contribute to depersonalization symptoms. Higher activity in the right parietal lobe's angular gyrus has been linked to more severe depersonalisation, supporting this idea. [5]

Potential involvement of serotonergic, endogenous opioid, and glutamatergic NMDA pathways has also been proposed, alongside alterations in metabolic activity in the sensory association cortex, prefrontal hyperactivation, and limbic inhibition in response to aversive stimuli revealed by brain imaging studies. [14]

In addition to this, research suggests that individuals with depersonalization often exhibit autonomic blunting, characterized by reduced physiological responses to stressors or emotional stimuli. This blunting may reflect a diminished capacity to engage with the external world or to experience emotions fully, contributing to the subjective sense of detachment from oneself. [2] Additionally, dysregulation of the HPA axis, which governs the body's stress response system, is frequently observed in individuals who experience depersonalization. This dysregulation can manifest as alterations in cortisol levels and responsiveness to stress, potentially exacerbating feelings of detachment and unreality. [5]

Ultimate Mechanism

Depersonalization is a classic response to acute trauma, and may be highly prevalent in individuals involved in different traumatic situations including motor vehicle accident, and imprisonment. [6]

Psychologically depersonalization can, just like dissociation in general, be considered a type of coping mechanism, used to decrease the intensity of unpleasant experience, whether that is something as mild as stress or something as severe as chronically high anxiety and post-traumatic stress disorder. [37]

The decrease in anxiety and psychobiological hyperarousal helps preserving adaptive behaviors and resources under threat or danger. [6]

Depersonalization is an overgeneralized reaction in that it doesn't diminish just the unpleasant experience, but more or less all experience – leading to a feeling of being detached from the world and experiencing it in a more bland way. An important distinction must be made between depersonalization as a mild, short-term reaction to unpleasant experience and depersonalization as a chronic symptom stemming from a severe mental disorder such as PTSD or dissociative identity disorder. [37]

Chronic symptoms may represent persistence of depersonalization beyond the situations under threat. [6]

Treatment

Currently, no universally accepted treatment guidelines have been established for depersonalization. Pharmacotherapy remains a primary avenue of treatment, with medications such as clomipramine, fluoxetine, lamotrigine, and opioid antagonists being commonly prescribed. However, it is important to note that none of these medications have demonstrated a potent anti-dissociative effect in managing symptoms. [14]

In addition to pharmacological interventions, various psychotherapeutic techniques have been employed in attempts to alleviate depersonalization symptoms. Modalities such as trauma-focused therapy and cognitive-behavioral techniques have been utilized, although their efficacy remains uncertain and not firmly established. [14]

An attempt at a visual representation of depersonalization Depersonalization Disorder by Boris D. Ognenovich.png
An attempt at a visual representation of depersonalization

Treatment is dependent on the underlying cause, whether it is organic or psychological in origin. If depersonalization is a symptom of neurological disease, then diagnosis and treatment of the specific disease is the first approach. Depersonalization can be a cognitive symptom of such diseases as amyotrophic lateral sclerosis, Alzheimer's disease, multiple sclerosis (MS), or any other neurological disease affecting the brain.[ citation needed ] For those with both depersonalization and migraine, tricyclic antidepressants are often prescribed.

If depersonalization is a symptom of psychological causes such as developmental trauma, treatment depends on the diagnosis. In case of dissociative identity disorder or DD-NOS as a developmental disorder, in which extreme developmental trauma interferes with formation of a single cohesive identity, treatment requires proper psychotherapy, and—in the case of additional (co-morbid) disorders such as eating disorders—a team of specialists treating such an individual. It can also be a symptom of borderline personality disorder, which can be treated in the long term with proper psychotherapy and psychopharmacology. [38]

The treatment of chronic depersonalization is considered in depersonalization disorder.

A 2001 Russian study showed that naloxone, a drug used to reverse the intoxicating effects of opioid drugs, can successfully treat depersonalization disorder. According to the study: "In three of 14 patients, depersonalization symptoms disappeared entirely and seven patients showed a marked improvement. The therapeutic effect of naloxone provides evidence for the role of the endogenous opioid system in the pathogenesis of depersonalization." [39] The anticonvulsant drug lamotrigine has shown some success in treating symptoms of depersonalization, often in combination with a selective serotonin reuptake inhibitor and is the first drug of choice at the depersonalisation research unit at King's College London. [38] [40] [41]

Research Directions

Interest in DPDR has increased over the past few decades, leading to a large accumulation of literature on dissociative disorders. There has been a shift towards the use of research studies, rather than case studies to understand depersonalization. [2] However, there remains a lack of solid consensus on its definition and scales used for assessment. [2] [14] Salami and colleagues argued that studies of electrophysiological depersonalization-derealization markers are urgently needed, and that future research should use analysis methods that can account for the integration of interoceptive and exteroceptive signals. [5]

The Depersonalisation Research Unit at the Institute of Psychiatry in London conducts research into depersonalization disorder. [42] Researchers there use the acronym DPAFU (Depersonalisation and Feelings of Unreality) as a shortened label for the disorder.

In a 2020 article in the Journal Nature, Vesuna, et al. describe experimental findings which show that layer 5 of the retrosplenial cortex is likely responsible for dissociative states of consciousness in mammals.

See also

Related Research Articles

Post-traumatic stress disorder (PTSD) is a mental and behavioral disorder that develops from experiencing a traumatic event, such as sexual assault, warfare, traffic collisions, child abuse, domestic violence, or other threats on a person's life or well-being. Symptoms may include disturbing thoughts, feelings, or dreams related to the events, mental or physical distress to trauma-related cues, attempts to avoid trauma-related cues, alterations in the way a person thinks and feels, and an increase in the fight-or-flight response. These symptoms last for more than a month after the event. Young children are less likely to show distress, but instead may express their memories through play. A person with PTSD is at a higher risk of suicide and intentional self-harm.

Dissociatives, colloquially dissos, are a subclass of hallucinogens that distort perception of sight and sound and produce feelings of detachment – dissociation – from the environment and/or self. Although many kinds of drugs are capable of such action, dissociatives are unique in that they do so in such a way that they produce hallucinogenic effects, which may include dissociation, a general decrease in sensory experience, hallucinations, dream-like states or anesthesia. Despite most dissociatives' main mechanism of action being tied to NMDA receptor antagonism, some of these substances, which are nonselective in action and affect the dopamine and/or opioid systems, may be capable of inducing more direct and repeatable euphoria or symptoms which are more akin to the effects of typical "hard drugs" or common drugs of abuse. This is likely why dissociatives are considered to be addictive with a fair to moderate potential for abuse, unlike psychedelics. Despite some dissociatives, such as phencyclidine (PCP) possessing stimulating properties, most dissociatives seem to have a general depressant effect and can produce sedation, respiratory depression, nausea, disorientation, analgesia, anesthesia, ataxia, cognitive and memory impairment as well as amnesia.

Dissociation is a concept that has been developed over time and which concerns a wide array of experiences, ranging from a mild emotional detachment from the immediate surroundings, to a more severe disconnection from physical and emotional experiences. The major characteristic of all dissociative phenomena involves a detachment from reality, rather than a false perception of reality as in psychosis.

Psychological trauma is an emotional response caused by severe distressing events that are outside the normal range of human experiences. It must be understood by the affected person as directly threatening the affected person or their loved ones with death, severe bodily injury, or sexual violence; indirect exposure, such as from watching television news, may be extremely distressing and can produce an involuntary and possibly overwhelming physiological stress response, but does not produce trauma per se. Examples include violence, rape, or a terrorist attack.

Depersonalization-derealization disorder is a mental disorder in which the person has persistent or recurrent feelings of depersonalization and/or derealization. Depersonalization is described as feeling disconnected or detached from one's self. Individuals may report feeling as if they are an outside observer of their own thoughts or body, and often report feeling a loss of control over their thoughts or actions. Derealization is described as detachment from one's surroundings. Individuals experiencing derealization may report perceiving the world around them as foggy, dreamlike, surreal, and/or visually distorted.

Dysphoria is a profound state of unease or dissatisfaction. It is the semantic opposite of euphoria. In a psychiatric context, dysphoria may accompany depression, anxiety, or agitation.

Acute stress reaction and acute stress disorder (ASD) is a psychological response to a terrifying, traumatic or surprising experience. Combat stress reaction (CSR) is a similar response to the trauma of war. The reactions may include but are not limited to intrusive or dissociative symptoms, and reactivity symptoms such as avoidance or arousal. It may be exhibited for days or weeks after the traumatic event. If the condition is not correctly addressed, it may develop into post-traumatic stress disorder (PTSD).

<span class="mw-page-title-main">Hallucinogen persisting perception disorder</span> Medical condition

Hallucinogen persisting perception disorder (HPPD) is a non-psychotic disorder in which a person experiences apparent lasting or persistent visual hallucinations or perceptual distortions after using drugs, including but not limited to psychedelics, dissociatives, entactogens, tetrahydrocannabinol (THC), and SSRIs. Despite being designated as a hallucinogen-specific disorder, the specific contributory role of psychedelic drugs is unknown.

Dissociative disorders (DDs) are a range of conditions characterized by significant disruptions or fragmentation "in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior." Dissociative disorders involve involuntary dissociation as an unconscious defense mechanism, wherein the individual with a dissociative disorder experiences separation in these areas as a means to protect against traumatic stress. Some dissociative disorders are caused by major psychological trauma, though the onset of depersonalization-derealization disorder may be preceded by less severe stress, by the influence of psychoactive substances, or occur without any discernible trigger.

<span class="mw-page-title-main">Emotional detachment</span> Inability and/or disinterest in emotionally connecting to others

In psychology, emotional detachment, also known as emotional blunting, is a condition or state in which a person lacks emotional connectivity to others, whether due to an unwanted circumstance or as a positive means to cope with anxiety. Such a coping strategy, also known as emotion-focused coping, is used when avoiding certain situations that might trigger anxiety. It refers to the evasion of emotional connections. Emotional detachment may be a temporary reaction to a stressful situation, or a chronic condition such as depersonalization-derealization disorder. It may also be caused by certain antidepressants. Emotional blunting, also known as reduced affect display, is one of the negative symptoms of schizophrenia.

Complex post-traumatic stress disorder is a stress-related mental disorder generally occurring in response to complex traumas, i.e., commonly prolonged or repetitive exposures to a series of traumatic events, within which individuals perceive little or no chance to escape.

A spectrum disorder is a disorder that includes a range of linked conditions, sometimes also extending to include singular symptoms and traits. The different elements of a spectrum either have a similar appearance or are thought to be caused by the same underlying mechanism. In either case, a spectrum approach is taken because there appears to be "not a unitary disorder but rather a syndrome composed of subgroups". The spectrum may represent a range of severity, comprising relatively "severe" mental disorders through to relatively "mild and nonclinical deficits".

A sympatholytic (sympathoplegic) drug is a medication that opposes the downstream effects of postganglionic nerve firing in effector organs innervated by the sympathetic nervous system (SNS). They are indicated for various functions; for example, they may be used as antihypertensives. They are also used to treat anxiety, such as generalized anxiety disorder, panic disorder and PTSD. In some cases, such as with guanfacine, they have also shown to be beneficial in the treatment of ADHD.

Derealization is an alteration in the perception of the external world, causing those with the condition to perceive it as unreal, distant, distorted or falsified. Other symptoms include feeling as if one's environment is lacking in spontaneity, emotional coloring, and depth. It is a dissociative symptom that may appear in moments of severe stress.

Interoceptive exposure is a cognitive behavioral therapy technique used in the treatment of panic disorder. It refers to carrying out exercises that bring about the physical sensations of a panic attack, such as hyperventilation and high muscle tension, and in the process removing the patient's conditioned response that the physical sensations will cause an attack to happen.

<span class="mw-page-title-main">Panic disorder</span> Anxiety disorder characterized by reoccurring unexpected panic attacks

Panic disorder is a mental and behavioral disorder, specifically an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.

Thought blocking is a neuropsychological symptom expressing a sudden and involuntary silence within a speech, and eventually an abrupt switch to another topic. Persons undergoing thought blocking may utter incomprehensible speech; they may also repeat words involuntarily or make up new words. The main causes of thought blocking are schizophrenia, anxiety disorders, petit mal seizures, post-traumatic stress disorder, bradyphrenia, aphasia, dementia and delirium.

Trauma-sensitive yoga is yoga as exercise, adapted from 2002 onwards for work with individuals affected by psychological trauma. Its goal is to help trauma survivors to develop a greater sense of mind-body connection, to ease their physiological experiences of trauma, to gain a greater sense of ownership over their bodies, and to augment their overall well-being. However, a 2019 systematic review found that the studies to date were not sufficiently robustly designed to provide strong evidence of yoga's effectiveness as a therapy; it called for further research.

Other specified dissociative disorder (OSDD) is a mental health diagnosis for pathological dissociation that matches the DSM-5 criteria for a dissociative disorder, but does not fit the full criteria for any of the specifically identified subtypes, which include dissociative identity disorder, dissociative amnesia, and depersonalization/derealization disorder, and the reasons why the previous diagnoses were not met are specified. "Unspecified dissociative disorder" is given when the clinician does not give a reason. The International Statistical Classification of Diseases and Related Health Problems (ICD-10) refers to the diagnosis as "Other dissociative and conversion disorders". Under the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), it was known as "Dissociative disorder not otherwise specified" (DDNOS).

The Multiscale Dissociation Inventory (MDI) is a comprehensive, self-administered, multiscale instrument developed by Paul F. Dell. It is designed to assess the entire domain of dissociative identity disorder phenomena. The MDI measures 14 major facets of pathological dissociation and uses 23 scales to diagnose dissociative disorders.

References

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  38. 1 2 Sierra, Mauricio; Baker, Dawn; Medford, Nicholas; Lawrence, Emma; Patel, Maxine; Phillips, Mary L.; David, Anthony S. (2006). "Lamotrigine as an Add-on Treatment for Depersonalization Disorder". Clinical Neuropharmacology . 29 (5): 253–258. doi:10.1097/01.WNF.0000228368.17970.DA. PMID   16960469. S2CID   38595510.
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  42. ↑ "Depersonalisation Research Unit - Institute of Psychiatry, London". Archived from the original on 2007-01-18. Retrieved 2006-11-07.

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