Depersonalization and social anxiety

Although the literature on depersonalization (DP) indicates links between DP and anxiety disorders, there has been no systematic investigation of the association of DP with social anxiety. The present study explores a hypothesized connection between DP and social anxiety by using correlative and regression analyses in a sample of 116 psychotherapy inpatients, 54 outpatients with epilepsy, and 31 nonpatients. Corresponding to our hypothesis, we found a connection of medium to large effect size between DP and social fears exceeding the impact of general psychopathologic symptom severity both for the psychotherapy patients and the nonpatients. The association of social anxiety with DP merits further research. A general consideration of DP in clinical and neurobiological trials on anxiety disorders like social phobia is warranted.

[Burn-out among personnel of prisons: Karasek's job demand-control model]

The main objective of the present research was to test a path model describing the effects of the dimensions of the Karasek's "job strain" model on burn-out among a sample of personnel of prisons (n=119). This model assumes that the combination of high job demands along with low decision latitude at work precipitates psychological strain and physical illness. Job demands refer to the perceived demands from job and others in the workplace. Decision latitude is an operationalization of the concept of control and has often been defined as the combination of job decision-making authority and the opportunity to use and develop skills on the job. The findings support this model. Indeed, high level of workload acts positively on emotional exhaustion and depersonalization; in contrast, high level of job decisions latitude acts negatively on emotional exhaustion and positively on personnel accomplishment. Limits of this study are discussed.

[Chronic depersonalisation following cannabis use]

A 19-year-old patient had developed a depersonalisation disorder following the use of considerable amounts of cannabis for several weeks two years before. The symptoms decreased sharply after treatment with a serotonergic antidepressant. In cases of persistent or recurrent symptoms of depersonalisation, both psychiatric and somatic causes should be looked for. In cases of primary depersonalisation, the use of (soft) drugs should be considered in the differential diagnosis. Various forms of pharmaco- and psychotherapy seem to be able to reduce the symptoms. However, the effectiveness of no treatment has yet been proven.

Dissociation, childhood interpersonal trauma, and family functioning in patients with somatization disorder

OBJECTIVE

The goals of this study were to determine 1) the occurrence of various dissociative phenomena in patients with somatization disorder, 2) the occurrence of six different types of childhood interpersonal trauma in these patients, and 3) the nature of these patients' early family environment.

METHOD

Twenty-two patients with somatization disorder and 19 medical comparison subjects completed the Structured Clinical Interview for DSM-IV Dissociative Disorders, the Childhood Trauma Interview, and the Family Functioning Scale.

RESULTS

The somatization disorder patients reported significantly higher level of dissociative amnesia than the comparison subjects. The two groups reported similar levels of depersonalization, derealization, identity confusion, and identity alteration. Somatization disorder patients reported significantly greater childhood emotional abuse and more severe forms of physical abuse, relative to the comparison subjects, with chronic emotional abuse being the best predictor of unexplained symptoms. Childhood sexual abuse, separation/loss, and witnessing violence were equally common in the two groups. The somatization disorder group reported significantly more family conflict and less family cohesion.

CONCLUSIONS

Only some types of dissociation are more severe in patients with somatization disorder, relative to medical comparison subjects. Many patients with somatization disorder are raised in an emotionally cold, distant, and unsupportive family environment characterized by chronic emotional and physical abuse. Sexual abuse is not a necessary prerequisite for the disorder.

[Depersonalization--current data]

OBJECTIVE

Depersonalization is a fascinating clinical phenomenon referring to a self-consciousness disorder, characterized by emotional detachment from one's own feelings, thoughts, or actions. This article intends to summarize the current literature in this area.

METHOD

Using the Medline data base, we reviewed literature addressing the clinical, etiology, nosology, physiopathology, and treatment of depersonalization.

CONCLUSIONS

Derealization means that perception of the world and of external reality are altered. These 2 phenomena are often associated. They are not specific to any psychiatric entity and are reported in many different psychiatric syndromes. Many factors, including use of different substances, are involved in their onset. The physiopathology is still little known. However, some conceptual models suggest partial amygdala inhibition combined with activation of other amygdaloid structures. A serotoninergic functioning impairment is indicated in different pharmacologic studies. Different psychotropic drugs, especially serotoninergic antidepressants, have been proposed for pharmacotherapy; however, there are no conclusive randomized studies, and the contribution of psychotherapy in treating these patients is still questioned.

[The measurement of the depersonalisation-derealisation-syndrome with the German version of the Cambridge Depersonalisation Scale (CDS)]

Self-rating scales have proved to be essential in the study of depersonalisation, which regrettably, is still seldom recognised in clinical practice. In recent studies the Cambridge Depersonalisation Scale (CDS) has emerged as an useful instrument for the study of depersonalisation. Here we report a validation study of the authorised German version of the CDS in a sample of 91 inpatients, 43 of whom had pathological depersonalisation and 48 without pathological depersonalisation. The SCID-D Interview for depersonalisation and derealisation was used as the gold standard and the German version of the Dissociative Experiences Scale was used to test the external validity of the scale. The German version of the CDS was found to have high internal consistency and reliability (alpha = 0,95 and Guttman Split-half = 0,95) and could differentiate patients with pathological depersonalisation from the control group. We therefore conclude that the German version of the CDS can be considered as reliable and valid.

Depersonalisation disorder: a contemporary overview

Depersonalisation disorder is characterised by prominent depersonalisation and often derealisation, without clinically notable memory or identity disturbances. The disorder has an approximately 1 : 1 gender ratio with onset at around 16 years of age. The course of the disorder is typically long term and often continuous. Mood, anxiety and personality disorders are often comorbid with depersonalisation disorder but none predict symptom severity. The most common immediate precipitants of the disorder are severe stress, depression and panic, and marijuana and hallucinogen ingestion. Depersonalisation disorder has also been associated with childhood interpersonal trauma, in particular emotional maltreatment. Neurochemical findings have suggested possible involvement of serotonergic, endogenous opioid and glutamatergic NMDA pathways. Brain imaging studies in depersonalisation disorder have revealed widespread alterations in metabolic activity in the sensory association cortex, as well as prefrontal hyperactivation and limbic inhibition in response to aversive stimuli. Depersonalisation disorder has also been associated with autonomic blunting and hypothalamic-pituitary-adrenal axis dysregulation. To date, 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.

Dissociation in undergraduate students: disruptions in executive functioning

The concept of dissociation refers to disruptions in attentional control. Attentional control is an executive function. Few studies have addressed the link between dissociation and executive functioning. Our study investigated this relationship in a sample of undergraduate students (N = 185) who completed the Dissociative Experiences Scale and the Random Number Generation Task. We found that minor disruptions in executive functioning were related to a subclass of dissociative experiences, notably dissociative amnesia and the Dissociative Experiences Scale Taxon. However, the two other subscales of the Dissociative Experiences Scale, measuring depersonalization and absorption, were unrelated to executive functioning. Our findings suggest that a failure to inhibit previous responses might contribute to the pathological memory manifestations of dissociation.

Die Erfassung des Depersonalisations- Derealisationssyndroms mit dem Fragebogen zu Dissoziativen Symptoment

OBJECTIVES

The goal of this study is to investigate the applicability of the German adaptation of the Dissociative Experiences Scale, the "Fragebogen zu dissoziativen Symptomen (FDS)", for research on depersonalization (DP) and derealization (DR), and to elucidate the phenomenology of DP / DR.

METHODS

101 consecutively recruited inpatients were diagnosed with the German version of the Structured Clinical Interview for DSM-IV Dissociative Disorders for depersonalization/derealization. Furthermore, the FDS and the SCL-90-R were administered.

RESULTS

47 of 101 Patients were diagnosed with pathological DP / DR. The mean score of the DES scale of the FDS was 32.00 +/- 15.52. A cut-off score of 17.5 for the DES scale of the FDS yielded a 83.0 % sensitivity and 77.8 % specificity. Depressive disorders, anxiety disorders and trauma-associated disorders were the most common comorbidity.

CONCLUSIONS

The findings are comparable to the Anglo-American samples. The FDS was found to be quite effective for screening of DP / DR. The three-factor solution of the FDS was not well supported in this sample.

[Depersonalization: from disorder to the symptom]

In contrast with the growing interest in dissociative disorders over the last few years, depersonalization continues to be very scarcely approached. There is no agreement among clinicians regarding the concept of depersonalization, and little is known about its etiology, epidemiology and treatment. This paper has two main aims: first, review the literature on this pathology focusing on nosological, historical, psychophysiological and treatment aspects, and second, explore the incidence of the depersonalization symptom in other psychiatric conditions, in particular in panic disorder. The Medline database over the last 5 years has been used for these purposes, and lack of studies on this subject has been found, especially regarding therapeutic issues. Some of the most relevant findings suggest that depersonalization, when associated to panic disorder, could correspond to the most severe forms of this disorder.

The epidemiology of depersonalisation and derealisation. A systematic review

BACKGROUND

Symptoms of depersonalisation (DP) and derealisation (DR) are increasingly recognised in both clinical and non-clinical settings, but their importance and underlying pathophysiology is only now being addressed.

METHODS

This paper is a systematic review of the current state of knowledge about the prevalence of depersonalisation and derealisation using computerised databases and citation searches. All potential studies were examined and numerical data included. Three categories of study are reviewed: questionnaire and interview surveys of selected student and non-clinical samples; population-based community surveys using standardised diagnostic interviews; and clinical surveys of depersonalisation/derealisation symptoms occurring within inpatients with psychiatric disorders. In addition, we present newly analysed data of the prevalence of depersonalisation/derealisation from five large population-based studies.

RESULTS

Epidemiological surveys demonstrate that transient symptoms of depersonalisation/derealisation in the general population are common, with a lifetime prevalence rate of between 26 and 74% and between 31 and 66% at the time of a traumatic event. Community surveys employing standardised diagnostic interviews reveal rates of between 1.2 and 1.7 % for one month prevalence in a UK sample and a 2.4% current prevalence rate in a Canadian sample. Current prevalence rates in samples of consecutive inpatient admissions are reported between 1 and 16%, although screening measures employed may have resulted in these being an underestimate. Prevalence rates in clinical samples of specific psychiatric disorders vary between 30% of war veterans with PTSD and 60% of those with unipolar depression. There is a high prevalence within panic disorder with rates varying from 7.8 to 82.6%.

DISCUSSION

DP and DR symptoms are common in normal and psychiatric populations, but prevalence estimates are hampered by inconsistent definitions and the use of variable time-frames. Population-based surveys using diagnostic interviews yield prevalence rates of clinically significant DP/DR in the region of 1-2%. Surveys of clinical populations in which common screening and assessment instruments were used also yield consistently high prevalence rates. The use of reliable diagnostic assessments and rating scales is needed. The relationship between DP/DR and certain other psychiatric disorders (e. g. panic) suggests possible common pathophysiological or aetiological factors.

Examination of the pathological dissociation taxon in depersonalization disorder

In recent years, the pathologic dissociation taxon developed by Waller, Putnam, and Carlson (Psychological Methods 1:300-321, 1996) from a Dissociative Identity Disorder (DID) sample has been increasingly used in studies of dissociation in general. However, the taxon's convergence with dissociative diagnoses other than DID, as well as the taxon's central premise that pathologic dissociation is a categorical rather than a dimensional construct, remain areas of exploration. This report examines the applicability of the pathologic dissociation taxon to Depersonalization Disorder (DPD). The Dissociative Experiences Scale was administered to 100 consecutively recruited DPD subjects diagnosed by semistructured clinical interview and by the SCID-D. Taxon membership probability was calculated using the recommended SAS scoring program. Approximately 2/3 of subjects (N = 64) had a very high probability (>.80) of belonging to the taxon, while 1/3 of subjects had a very low probability (<.10) of belonging to the taxon. A taxon cutoff score of 13 yielded an 81% sensitivity in detecting the presence of DPD. The modest convergence between taxonic membership and clinical dissociative disorder diagnosis suggests that the taxon may have important limitations in its use, at least when applied to DPD in its current form. As previously, we continue to recommend a low taxon cutoff score (13) for the sensitive detection of depersonalization disorder. The inference that pathologic dissociation is a unitary and categorical entity is also discussed.

Basal norepinephrine in depersonalization disorder

In contrast to the noradrenergic dysregulation described in PTSD, little is known regarding noradrenergic function in dissociative disorders. The purpose of this preliminary study was to investigate basal norepinephrine in depersonalization disorder (DPD). Nine subjects with DSM-IV DPD, without lifetime PTSD, were compared to nine healthy comparison (HC) subjects. Norepinephrine was measured via 24-h urine collection and three serial plasma determinations. Groups did not differ significantly in plasma norepinephrine levels. Compared to the HC group, the DPD group demonstrated significantly higher urinary norepinephrine, only prior to covarying for anxiety. The DPD group also demonstrated a highly significant inverse correlation between urinary norepinephrine and depersonalization severity (r=-0.88). Norepinephrine and cortisol levels (reported in a prior study) were not intercorrelated. We concluded that although dissociation accompanied by anxiety was associated with heightened noradrenergic tone, there was a marked basal norepinephrine decline with increasing severity of dissociation. The findings are in concordance with the few reports on autonomic blunting in dissociation and merit further investigation.

Feeling unreal: a depersonalization disorder update of 117 cases

BACKGROUND

Despite a surge of interest and literature on depersonalization disorder in recent years, a large series of individuals with the disorder has not been described to date. In this report, we systematically elucidate the phenomenology, precipitants, antecedents, comorbidity, and treatment history in such a series.

METHOD

117 adult subjects with depersonalization disorder (DSM-III-R/DSM-IV criteria) consecutively recruited to a number of depersonalization disorder research studies were administered structured and semistructured diagnostic interviews and the Dissociative Experiences Scale. Data were gathered from 1994 to 2000.

RESULTS

The illness had an approximately 1:1 gender ratio with onset around 16 years of age. The course was typically chronic and often continuous. Illness characteristics such as onset, duration, and course were not associated with symptom severity. Mood, anxiety, and personality disorders were frequently comorbid, but none predicted depersonalization severity. The most common immediate precipitants of the disorder were severe stress, depression, panic, marijuana ingestion, and hallucinogen ingestion, and none of these predicted symptom severity. Negative affects, stress, perceived threatening social interaction, and unfamiliar environments were some of the more common factors leading to symptom exacerbation. Conversely, comforting interpersonal interactions, intense emotional or physical stimulation, and relaxation tended to diminish symptom intensity. There were no significant gender differences in the clinical features of the disorder. In this sample, depersonalization tended to be refractory to various medication and psychotherapy treatments.

CONCLUSION

The characteristics of depersonalization disorder found in this sample, the largest described to date, are in good accord with previous literature. The study highlights the need for novel therapeutic approaches to treat depersonalization disorder. Novel medication classes, as well as novel psychotherapeutic techniques that build on the reported symptom fluctuation factors, may prove helpful in the future.

Depersonalization disorder: a functional neuroanatomical perspective

Clinical reports of depersonalization suggest that attenuated emotional experience is a central feature of the condition. Patients typically complain of emotional numbness and some patients ascribe their feelings of unreality to a lack of affective "colouring" in things perceived. Recent neuroimaging and psychophysiological studies support these assumptions as they show both attenuated autonomic responses in depersonalization, and decreased activity within neural regions important for the generation of affective responses to emotive stimuli. Furthermore, findings from neuroimaging studies indicate increased prefrontal cortical activity in depersonalised patients, particularly within regions associated with contextualization and appraisal of emotionally-salient information rather than mood induction per se. Taken together, these finding suggest that symptoms of depersonalization, and in particular emotional numbing, may be related to a reversal of normal patterns of autonomic and neural response to emotive stimuli.

Confirmatory factor analysis of the Maslach Burnout Inventory among Florida nurses

Burnout among human service professionals, such as nurses, has been studied in various countries for years using the Maslach Burnout Inventory (MBI). This paper reports on confirmatory factor analyses using LISREL that examined the factorial validity of the MBI. The sample consisted of 151 registered nurses from west-central Florida. Modifications of the initial hypothesized three-factor structure were necessary to adequately fit the data. Findings are compared to the published normative values for the MBI and to similar studies of European nurses. Recommendations for measurement models of the MBI in future studies that use structural equation modeling techniques are offered.

Instrument to assess depersonalization-derealization in panic disorder

There is a long history of scholarly interest on depersonalization-derealization (DD) and its role in clinical anxiety, but there is a paucity of appropriate assessment instruments available. Our objective was to develop and evaluate a self-report measure of DD for use with clinically anxious patients. Panic disorder patients (n=169) were surveyed about DD experiences and provided data on a new item pool for psychometric development. DD episodes were common and a 28-item Depersonalization-Derealization Inventory was found to possess good reliability and validity. DD appears to be prevalent and clinically relevant in panic disorder. Continued study of DD is warranted and may be facilitated by the availability of a suitable instrument with promising psychometric properties. A 12-item version of the instrument may be appropriate as a brief screen.

Autonomic response in depersonalization disorder

BACKGROUND

Emotional-processing inhibition has been suggested as a mechanism underlying some of the clinical features of depersonalization and/or derealization. In this study, we tested the prediction that autonomic response to emotional stimuli would be reduced in patients with depersonalization disorder.

METHODS

The skin conductance responses of 15 patients with chronic depersonalization disorder according to DSM-IV, 15 controls, and 11 individuals with anxiety disorders according to DSM-IV, were recorded in response to nonspecific elicitors (an unexpected clap and taking a sigh) and in response to 15 randomized pictures with different emotional valences: 5 unpleasant, 5 pleasant, and 5 neutral.

RESULTS

The skin conductance response to unpleasant pictures was significantly reduced in patients with depersonalization disorder (magnitude of 0.017 micro siemens in controls and 0.103 micro siemens in patients with anxiety disorders; P =.01). Also, the latency of response to these stimuli was significantly prolonged in the group with depersonalization disorder (3.01 seconds compared with 2.5 and 2.1 seconds in the control and anxiety groups, respectively; P =.02). In contrast, latency to nonspecific stimuli (clap and sigh) was significantly shorter in the depersonalization and anxiety groups (1.6 seconds) than in controls (2.3 seconds) (P =.03).

CONCLUSIONS

In depersonalization disorder, autonomic response to unpleasant stimuli is reduced. The fact that patients with depersonalization disorder respond earlier to a startling noise suggests that they are in a heightened state of alertness and that the reduced response to unpleasant stimuli is caused by a selective inhibitory mechanism on emotional processing.

The spectrum of organic depersonalization: a review plus four new cases

Depersonalization and derealization are commonly reported in the general population as a response to stress. The symptoms have also been described in patients with a primary psychiatric or organic diagnosis, where their secondary status precludes a DSM-IV diagnosis of depersonalization disorder. The authors present 4 new cases of depersonalization in patients with an underlying organic condition, along with 47 cases from the literature in which the available information permits diagnosis of organic depersonalization. Information from case series documenting depersonalization in the context of medical illnesses is also presented and the underlying etiology discussed. Epilepsy and migraine appear to be the disorders most commonly associated with depersonalization. Left-sided temporal lobe dysfunction and anxiety are suggested as factors in the development of depersonalization; however, further studies are needed to determine the relationship. The introduction to the DSM-IV of an organic subtype of depersonalization disorder would facilitate research in this area.

[Personal peculiarities of epileptic patients with depersonalization in the interictal period]

Depersonalization states, expressed in interictal period, were analyzed in 23 patients. Depersonalization state occurs only in patients with partial complex seizures with epileptic focus in the temporal areas of the right hemisphere and in the mediobasal frontal areas of the left hemisphere. Also, compared to healthy subjects, schizoid personality features by MMPI and Rorshach psychological tests were found in these patients. The depersonalization states studied were defined as neurotic ones, because they manifested after psychotraumatic situation and did not recur after psychotherapy.

The relationship of akathisia with suicidality and depersonalization among patients with schizophrenia

An association of suicidality and depersonalization with akathisia has been reported, but it is not clear whether these phenomena are specific to akathisia or are nonspecific manifestations of distress. The authors used the Barnes Akathisia Rating Scale, Brief Psychiatric Rating Scale, and Hamilton Rating Scale for Depression (Ham-D) to examine the relationships between suicidality, depersonalization, dysphoria, and akathisia in 68 patients with schizophrenia or schizophreniform disorder. Akathisia was associated with higher scores on the Ham-D ratings of suicidality, depersonalization, and agitation. In a logistic regression model, depressive mood and subjective awareness of akathisia appeared to be the only predictors of suicidality and depersonalization, respectively. These findings support the association between akathisia and both suicidality and depersonalization. However, these symptoms appear to be nonspecific responses to accompanying depressive mood and the subjective awareness of the akathisia syndrome, respectively.

Separating depersonalisation and derealisation: the relevance of the "lesion method"

OBJECTIVES

Depersonalisation (DP) and derealisation (DR) are often met with in patients with a wide range of localisable neurological conditions. This suggests that the "lesion method" might be a valid approach to study the neurobiology of DP/DR. However, the fact that anxiety can trigger DP/DR makes it difficult to establish whether the presence of DP/DR in neurological patients is mainly determined by coexisting anxiety or by lesion location. To overcome this difficulty, we suggest the study of neurological phenomena, which although not considered as DP/DR, bear enough phenomenological resemblance with them as to warrant their use as models.

METHODS

One patient with "visual hypoemotionality" and another with "hemiasomatognosia" are described in detail together with a selective literature review.

RESULTS

Complaints of patients with visual hypoemotionality are indistinguishable from those of patients with "visual derealisation". There is also a phenomenological overlap between "asomatognosia" and the symptom of "body alienation", which is a central feature of depersonalisation.

CONCLUSIONS

Phenomenological similarities between visual hypoemotionality and DR suggest that a disruption of the process by means of which perception becomes emotionally coloured may be an underlying mechanism in both conditions. Likewise, phenomenological overlaps with asomatognosia suggest that DP might result from parietal mechanisms disrupting the experience of body ownership and agency. These findings give validity to the notion that DP and DR may have distinct neurobiological mechanisms.

[Concept of the person in psychiatry]

At first sight, the concept of "person" appears in psychiatric terminology only in the negative sense, i.e., as in depersonalization. However, self-alienation may be regarded as the hallmark of mental illness in general and is based on the ambiguous structure of human personality itself. Thorough analysis of the concept of the person is therefore indispensable to understanding psychopathology. This paper focuses on the contrast of "persona" ("mask" or "role") on the one hand to "person" as an individual self on the other. Their dialectical relation derives from basic anthropological structures such as sociality, self-reference, self-transcendence, and fictionality. As can be shown, the historical and cultural ontogeny of the personality includes experiences of self-alienation which may become relevant for psychiatry as depersonalization syndromes. The example of depression is used to illustrate vital and emotional depersonalization, whereas schizophrenia may be described as "intentional depersonalization." Following this line of reasoning, the classic schizophrenic experiences of alien control or thought insertion are interpreted as a disturbance in the fundamental personality structures.

Personality factors associated with dissociation: temperament, defenses, and cognitive schemata

OBJECTIVE

The purpose of this study was to investigate temperamental, psychodynamic, and cognitive factors associated with dissociation.

METHOD

Fifty-three subjects with DSM-IV-defined depersonalization disorder and 22 healthy comparison subjects were administered the Dissociative Experiences Scale, the Tridimensional Personality Questionnaire, the Defense Style Questionnaire, and the Schema Questionnaire.

RESULTS

Subjects with depersonalization disorder demonstrated significantly greater harm-avoidant temperament, immature defenses, and over-connection and disconnection cognitive schemata than comparison subjects. Within the group of subjects with depersonalization disorder, dissociation scores significantly correlated with the same variables.

CONCLUSIONS

Particular personality factors may render individuals more vulnerable to dissociative symptoms. Risk factors associated with dissociative disorders merit further study.

Depersonalization disorder: thinking without feeling

Patients with depersonalization disorder (DP) experience a detachment from their own senses and surrounding events, as if they were outside observers. A particularly common symptom is emotional detachment from the surroundings. Using functional magnetic resonance imaging (fMRI), we compared neural responses to emotionally salient stimuli in DP patients, and in psychiatric and healthy control subjects. Six patients with DP, 10 with obsessive-compulsive disorder (OCD), and six volunteers were scanned whilst viewing standardized pictures of aversive and neutral scenes, matched for visual complexity. Pictures were then rated for emotional content. Both control groups rated aversive pictures as much more emotive, and demonstrated in response to these scenes significantly greater activation in regions important for disgust perception, the insula and occipito-temporal cortex, than DP patients (covarying for age, years of education and total extent of brain activation). In DP patients, aversive scenes activated the right ventral prefrontal cortex. The insula was activated only by neutral scenes in this group. Our findings indicate that a core phenomenon of depersonalization--absent subjective experience of emotion--is associated with reduced neural responses in emotion-sensitive regions, and increased responses in regions associated with emotion regulation.

[Study of dissociative disorders and depersonalization in a sample of young adult French population]

Questioned by several researches about dissociative disorders, the authors study differences established on the nosographic register, through a quantitative study and a psychodynamic argumentation in a sample of french population. From the utilisation of the Dissociative Experiences Scale (DES) created by Bernstein E and Putnam FW (1986), which is an excellent screening tool for dissociative disorders and constructed on DSM II diagnostic criterions, the authors will show the interest of a psychodynamic analysis of dissociative disorders, in the face of the diagnostic difficulty in relation to several approaches of this concept. This difficulty is studied giving the background to dissociative disorders and depersonalization. Ionescu (1999) shows that between 1890 and 1910 dissociation represents one of major themes of psychology, psychopathology and psychiatry. Then, this interest about dissociation decreases and will be almost non-existent in the middle of the twentieth century. The interest for dissociative disorder will grow in the eighties with north-american studies about multiple personality disorders. Until 1980, dissociative disorders exist in DSM II as a list of symptoms included into hysterical neurosis, among the conversive disorders. In 1980, the publication of DSM III replaces the notion of hysteria with the notion of dissociative disorder. In this way, we can see on the one hand somatoform disorders quarterly corresponding to the ancient version of conversive hysteria, and on the other hand dissociative disorders characterized by a perturbation of consciousness, memory, identity or perception of environment. In 1994, The DSM IV delete the notion of hysteria and neurosis and keeps only the notion of dissociative disorders. They include now the five following categories: dissociative amnesia, dissociative fugue, depersonalization disorder, dissociative identity disorder, dissociative disorder not otherwise specified (including derealization). Depersonalization disorders consist of "persistent or recurrent episodes of depersonalization characterized by a feeling of detachment or estrangement from one's self. The individual may feel like an automation or like he or she is living in a dream or movie" (DSM IV). Depersonalization disorder cannot be diagnosed if it is part of schizophrenia, panic disorder, acute stress disorder or dissociative identity disorder. Various depressive disorders, hypocondriasis or obsessive-compulsive disorders can accompany depersonalization disorder. The first purpose of this study will search the frequency of dissociative disorders and depersonalization in a sample of normal population. Further, the inclusion of depersonalization amongst dissociative disorders seems not so evident: depersonalization belongs to self-consciousness disorder in french psychiatry. This fact seems more logical insofar as dissociative disorders have all together a memory and consciousness perturbation, and this perturbation is missing from depersonalization's feeling. The second purpose will be to clarify and specify the particularity of depersonalization among dissociative diorders, from the psychopathological point of view.

METHODOLOGY

The sample (n = 248) is made up of french young adults aged 17 to 30 (mean age = 20, SD = 15 and 24% is male population). Subjects were streamming from universities. The screening tool which was used is the Dissociative Experiences Scale, a 28-item patient questionnaire regarding various dissociative symptoms. The subject is asked to indicate the percentage of time, to the nearest 5%, that particular symptom is experienced. The score is made by adding the various percentages and finding a mean that is expressed in numbers from 0 to 100. Normal scores are in the range of 5 to 15 in american adults.

RESULTS

The utilization of principal component analysis (PCA) with varimax rotation is justified by the will to compare this study with American's studies. The mean score obtained is 17.44%, and 13.3% of the scores exceed a psychiatric threshold at 30%. The descriptive analysis shows that the component 1 (PCA without varimax rotation) represents 33.02% of total explained variance. This result demonstrates that the structure of the DES is based on one concept, the same as the american population, it is the concept of dissociation. The Principal Component Analysis with varimax rotation of the DES ratings yielded a tree-factor solution: imaginative absorption (F1), depersonalization-derealization (F2) and dissociative amnesia (F3). Mean score for each factor is respectively: F1 = 21.56%, F2 = 13.95%, F3 = 11.04%. DES reliability was studied through computation of Cronbach's coefficient (0.92). The PCA with varimax rotation brings to the fore a full dissociative disorder without any trouble of memory and consciousness. This fact questions again once more the link between hysteria and dissociative disorders. There is here a clinical distinction between depersonalization-derealization and other dissociative disorders. Indeed, the absence of significant alteration of memory and conscience is specific of depersonalization and derealization in this study.

CONCLUSION

Finally, this study concurs with DSM IV dissociative criterions. At last, one factor of PCA is composed by the association of depersonalization and derealization, in contradiction with DSM IV definition. This result shows that, into the french population, we cannot divide the two concepts.

Basal activity of the hypothalamic-pituitary-adrenal axis in patients with depersonalization disorder

Depersonalisation disorder may occur during severe anxiety or following a traumatic event, suggesting a possible role of stress hormones. This study investigated basal activity of the hypothalamic-pituitary-adrenal (HPA) axis in patients with depersonalisation disorder. Salivary cortisol levels were measured at four time points over 12 h in patients with depersonalisation disorder (N=13), major depressive disorder (MDD, N=14) and healthy controls (N=13). Beck Depression Inventory scores were significantly higher in depersonalised subjects than controls, while MDD subjects demonstrated higher scores than both groups. Basal cortisol levels of depersonalised subjects were significantly lower than those of MDD subjects but not healthy controls. These results point to reduced basal activity of the HPA axis in depersonalisation disorder. This pilot study supports the distinction between depersonalisation disorder and major depressive disorder which should be examined in a larger sample.

Visual imagery and depersonalisation

Twenty-eight people diagnosed with depersonalisation disorder (DD) were assessed using self-report measures of imagery ability in relation to a range of symptoms and in comparison with age- and sex-matched controls. It was found that symptoms of depersonalisation as well as other dissociative symptoms and depressed mood correlated with impaired ability to generate visual images. This was particularly evident with images pertaining to the self and other people as opposed to objects. A subgroup of 10 patients was tested on a neuropsychological battery of visual perception tests and found to be unimpaired compared with normal controls and patients with obsessive compulsive disorder, despite subjective impairments in imagery and high symptom scores. The findings add further weight to the distinctions made between imagery and perceptual processes.

A case of depersonalization-derealization syndrome during treatment with quetiapine

A case who schizophrenia developed patient male of a 65-year-old is reported depersonalization-derealization syndrome following treatment with quetiapine, an atypical antipsychotic. The literature is reviewed for possible biological mechanisms that may account for this phenomenon.

The phenomenological stability of depersonalization: comparing the old with the new

The view that depersonalization is a stable syndrome became well established during the first half of the 20th century. Current operational definitions restrict depersonalization to the experience of unreality. This is likely to neglect clinical features of potential neurobiological relevance. By using the year 1946 as the dividing line, 200 cases of depersonalization disorder reported in the medical literature since 1898 were divided into two historical groups (1 and 2). The groups were then compared in terms of 18 phenomenological variables with a sample of 45 prospective cases of DSM-IV depersonalization disorder (group 3 or gold standard). Groups 1 and 2 differed in terms of their symptom profile, but the highest frequency that symptoms achieved in either group did not differ from the rates identified in group 3. A core of (invariable) symptoms, including emotional numbing, visual derealization, and altered body experience, was present throughout. These high rates of spontaneous reporting in all three groups may be explained by the fact that they all are accompanied by specific distress. With the exception of heightened self-observation and altered time experiencing, all other symptoms were significantly lower in group 2. The results suggest that the phenomenology of depersonalization has remained stable over the last 100 years. Our study found differences in frequency for some symptoms, but these are likely to have resulted from reporting biases, themselves governed by changing theoretical views. Clinical descriptions became poorer as the present is approached. This cannot be solely explained on the basis of empirical progress, and it is likely that theoretical biases also play a role. Because the neurobiological relevance of the symptoms of depersonalization remains unknown, it makes sense to continue collecting as many symptoms as possible, thereby avoiding both biased selection or premature closure.

A factor analytic and psychometric examination of pathology of separation-individuation

Two studies are described that attempt to determine if standard-scale-reduction techniques could yield a construct-valid diagnostic screen of pathology of separation-individuation for use in nonclinical university settings. In Study 1 (N = 210), a measure of pathology of separation-individuation (PATHSEP) was reduced successfully to a single, internally consistent factor, accounting for 36% of the variance. In Study 2 (N = 304), these items also coalesced around a single factor, accounting for 35% of the variance. Study 2 also showed that PATHSEP is correlated moderately and positively with indices of insecure attachment, with the Center for Epidemiological Studies-Depression Scale, and with indices of psychiatric symptomatology (Hopkins Symptom Checklist). PATHSEP also was associated with a poorer profile of adjustment to college. Males reported more pathology of separation-individuation than did females. Evidence supports the construct validity of a shortened version of PATHSEP. Directions for future research are noted.

The role of childhood interpersonal trauma in depersonalization disorder

OBJECTIVE

In contrast to trauma's relationship with the other dissociative disorders, the relationship of trauma to depersonalization disorder is unknown. The purpose of this study was to systematically investigate the role of childhood interpersonal trauma in depersonalization disorder.

METHOD

Forty-nine subjects with DSM-IV depersonalization disorder and 26 healthy comparison subjects who were free of lifetime axis I and II disorders and of comparable age and gender were administered the Dissociative Experiences Scale and the Childhood Trauma Interview, which measures separation or loss, physical neglect, emotional abuse, physical abuse, witnessing of violence, and sexual abuse.

RESULTS

Childhood interpersonal trauma as a whole was highly predictive of both a diagnosis of depersonalization disorder and of scores denoting dissociation, pathological dissociation, and depersonalization. Emotional abuse, both in total score and in maximum severity, emerged as the most significant predictor both of a diagnosis of depersonalization disorder and of scores denoting depersonalization but not of general dissociation scores, which were better predicted by combined emotional and sexual abuse. The majority of the perpetrators of emotional abuse were either or both parents. Although different types of trauma were modestly correlated, only a few of these relationships were statistically significant, underscoring the importance of comprehensively considering different types of trauma in research studies.

CONCLUSIONS

Childhood interpersonal trauma and, in particular, emotional abuse may play a role in the pathogenesis of depersonalization disorder. Compared to other types of childhood trauma, emotional maltreatment is a relatively neglected entity in psychiatric research and merits more attention.

A systematic investigation of 16 cases of neonaticide

OBJECTIVE

Neonaticide, or infant murder on the day of birth, is often preceded by denial of pregnancy. The preponderance of case reports of neonaticide describes a pattern of pregnancy denial, dissociation, and ego disorganization. The author systematically investigated the clinical characteristics of 16 women charged with homicide in the United States after alleged neonaticides.

METHOD

The women received a psychiatric evaluation and were administered the Dissociative Experiences SCALE:

RESULTS

Nearly all of the women reported similar precipitants and symptoms, including depersonalization, dissociative hallucinations, and intermittent amnesia at delivery.

CONCLUSIONS

The characteristics of the women in the study were similar to those reported in the literature on neonaticide. The existence of this common pattern suggests that treatment strategies can be designed for women at risk for neonaticide.

Development of a depersonalization severity scale

Our aim was to develop a clinician-rated scale assessing depersonalization severity for use in clinical trials of Depersonalization Disorder and trauma-related disorders in general. The 6-item Depersonalization Severity Scale (DSS) was administered to 63 participants with DSM-IV Depersonalization Disorder as diagnosed by the SCID-D, and its psychometric properties were examined. The sensitivity of the DSS and of the Dissociative Experiences Scale (DES) to treatment change was assessed in blinded, controlled settings. Individual items were widely distributed across the severity range. Interrater reliability was excellent and internal consistency was moderate. The DSS had high convergent and discriminant validity and was sensitive to treatment change. The DES was also sensitive to treatment change. We recommend piloting the DSS in future treatment trials of trauma-spectrum disorders.

Primary and secondary depersonalisation disorder: a psychometric study

INTRODUCTION

Depersonalisation may be part of a symptom-complex, a primary or a secondary disorder. Optimal methods of measurement and diagnosis have not been established.

METHODS

We assessed 42 patients with primary or secondary depersonalisation, plus psychiatric and non-psychiatric controls using a variety of self-report questionnaire scales including the Beck depression and anxiety Inventories, and one developed by the authors (the Fewtrell Depersonalisation Scale (FDS)). The correlations between the scales and measures of anxiety and depression were calculated, as were sensitivity and specificity against an operational case definition.

RESULTS

All the scales were highly correlated. All could distinguish depersonalisation cases from the rest but none could distinguish between primary and secondary depersonalisation disorder. Anxiety and especially depression were correlated with depersonalisation symptoms. The FDS had high sensitivity (85.7%) and specificity (92.3%) which compared favourably with other instruments. Patients with both derealisation and depersonalisation scored the highest on the FDS.

DISCUSSION

Depersonalisation disorder comprises a measurable cluster of symptoms which may be quantified with the help of self-report scales. Primary and secondary forms overlap, with depressed mood a frequent feature.

Feeling unreal: a PET study of depersonalization disorder

OBJECTIVE

The goal of this study was to assess brain glucose metabolism and its relationship to dissociation measures and clinical symptoms in DSM-IV depersonalization disorder.

METHOD

Positron emission tomography scans coregistered with magnetic resonance images of eight subjects with depersonalization disorder were compared to those of 24 healthy comparison subjects. The two groups did not differ in age, sex, education, performance on a baseline neuropsychological battery, or performance on a verbal learning task administered during [(18)F]fluorodeoxyglucose uptake. A cortical analysis by individual Brodmann's areas was performed.

RESULTS

Compared to the healthy subjects, subjects with depersonalization disorder showed significantly lower metabolic activity in right Brodmann's areas 22 and 21 of the superior and middle temporal gyri and had significantly higher metabolism in parietal Brodmann's areas 7B and 39 and left occipital Brodmann's area 19. Dissociation and depersonalization scores among the subjects with depersonalization disorder were significantly positively correlated with metabolic activity in area 7B.

CONCLUSIONS

Depersonalization appears to be associated with functional abnormalities along sequential hierarchical areas, secondary and cross-modal, of the sensory cortex (visual, auditory, and somatosensory), as well as areas responsible for an integrated body schema. These findings are in good agreement with the phenomenological conceptualization of depersonalization as a dissociation of perceptions as well as with the subjective symptoms of depersonalization disorder.

Depersonalization in cyberspace

We explored the possibility of carrying out clinical research on the Internet. To do so, we compared psychometric and demographic variables between two groups of sufferers of depersonalization disorder, one recruited via the Internet, the other from outpatients attending the Depersonalization Research Unit. No differences were found in demographics or features of depersonalization. Those seen in the clinic were, however, significantly more depressed. We then explored the answers to several questions posted on a depersonalization bulletin board by a second group of Internet users. Useful information on symptoms, precipitants, and treatment was gained. It is concluded that the Internet could become a valuable tool in clinical psychiatric research.

Depersonalization in panic disorder: a clinical study

Panic disorder (PD) has been hypothesized to be a heterogeneous entity, with distinct clinical subgroups. The presence of depersonalization during panic attacks may distinguish a specific subgroup of PD. We sought to analyze the differential features of a subgroup of PD patients with depersonalization. A total of 274 patients with PD were assessed and divided into 2 groups according to the presence or absence of depersonalization. The Structured Clinical Interview for DSM-III-R (SCID-UP-R) was used to assess PD and comorbid disorders. The clinical scales administered included the Hamilton Anxiety and Depression Rating Scale (HARS and HDRS), the Marks and Mathews Fears and Phobia Scale, Panic-Associated Symptom Scale (PASS), and a panic attack symptoms inventory. A total of 66 patients (24.1%) exhibited depersonalization during the attacks. Patients with depersonalization appeared to be younger and had an earlier age at onset. PD was more severe in the depersonalization group (greater number of attacks, worse level of functioning, and higher scores on most self-rating scales). Also, depersonalization patients showed more comorbidity with specific phobia. Our results support the view that PD with depersonalization may be considered a distinct and more severe subcategory of PD.

The Cambridge Depersonalization Scale: a new instrument for the measurement of depersonalization

Existing self-rating scales to measure depersonalization either show dubious face validity or fail to address the phenomenological complexity of depersonalization. Based on a comprehensive study of the phenomenology of this condition, a new self-rating depersonalization questionnaire was constructed. The Cambridge Depersonalization Scale is meant to capture the frequency and duration of depersonalization symptoms over the 'last 6 months'. It has been tested on a sample of 35 patients with DSM-IV depersonalization disorder, 22 with anxiety disorders, and 20 with temporal lobe epilepsy. Scores were compared against clinical diagnoses (gold standard) and correlated with the depersonalization subscale of the Dissociation Experiences Scale (DES). The scale was able to differentiate patients with DSM-IV depersonalization disorder from the other groups, and showed specific correlations with the depersonalization subscale of the DES (r=0.80; P=0.0007). The scale also showed high internal consistency and good reliability (Cronbach alpha and split-half reliability were 0.89 and 0.92, respectively). The instrument can, therefore, be considered as valid and reliable, and can be profitably used in both clinical and neurobiological research.

Childhood trauma and dissociative symptoms in panic disorder

OBJECTIVE

Childhood trauma has been associated with increased risk for both panic disorder and dissociative symptoms in adulthood. The authors hypothesized that among individuals with a primary diagnosis of panic disorder, those experiencing depersonalization/derealization during panic attacks would be more likely to have a history of childhood trauma.

METHOD

Rates of traumatic events were compared between panic disorder patients with (N=34) and without (N=40) prominent depersonalization/derealization during panic attacks. Symptom severity in the two groups was also examined.

RESULTS

Contrary to the authors' hypothesis, no evidence was found that depersonalization/derealization during panic attacks was associated with childhood trauma. Minimal differences in severity of illness were found between patients with dissociative symptoms and those without such symptoms.

CONCLUSIONS

This finding is consistent with a multifactorial model of dissociation. Factors other than childhood trauma and general psychopathology may underlie vulnerability to dissociative symptoms in panic disorder.

Feeling unreal: cognitive processes in depersonalization

OBJECTIVE

Depersonalization disorder is characterized by a detachment from one's sense of self and one's surroundings that leads to considerable distress and impairment yet an intact testing of reality. Depersonalized individuals often report difficulties in perception, concentration, and memory; however, data on their cognitive profiles are lacking.

METHOD

Fifteen patients with depersonalization disorder were compared to 15 matched normal comparison subjects on a comprehensive neuropsychological test battery that assessed cognitive function.

RESULTS

The subjects with depersonalization disorder showed a distinct cognitive profile. They performed significantly worse than the comparison subjects on certain measures of attention, short-term visual and verbal memory, and spatial reasoning within the context of comparable intellectual abilities.

CONCLUSIONS

The authors propose that depersonalization involves alterations in the attentional and perceptual systems, specifically in the ability to effortfully control the focus of attention. These early encoding deficits are hypothesized to have a deleterious effect on the short-term memory system; they manifest as deficits in the ability to take in new information but not in the ability to conceptualize and manipulate previously encoded information.