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Although not highly traumatized, the subjects with depersonalization disorder reported significantly more childhood trauma than the normal comparison subjects.
Depersonalization had been typically treatment refractory; only serotonin reuptake inhibitors and, to a lesser extent, benzodiazepines had been of any therapeutic benefit. Conclusions: This study supports the conceptualization of depersonaliza- tion disorder as a distinct disorder with a characteristic course that is independent of mood, anxiety, and personality symptoms. A subtle relationship may exist between childhood trauma and depersonalization disorder that merits further investigation.
The disorder appears to be highly treatment refractory, and prospective treatment trials are warranted. Am J Psychiatry ; — D epersonalization disorder is a fascinating psychi- atric disorder about which relatively little is known. Despite the surge of interest and the rediscovery however, this is uncertain given the paucity of data, the underreporting of symptoms by patients, and the un- derdiagnosis by clinicians.
In fact, a number of reports of dissociation in the last decade, depersonalization suggest that depersonalization is a rather common ex- disorder continues to be one of the least investigated, perience that spans from the normal to the pathological diagnosed, and written about dissociative conditions. About two-thirds of individuals subjected to life-threat- The incidence and prevalence of depersonalization ening danger report transient depersonalization 4.
In disorder are unknown, and there are limited data on its a large series of general psychiatric inpatients with vari- occurrence in community or clinical settings. Thus, it seems Received Nov. From the Department of Psychiatry, mon than expected. Mount Sinai School of Medicine. Address reprint requests to Dr. Psy- phrenia and Depression to Dr.
All sta- psychotherapeutic or pharmacological, exist. We therefore undertook the description of 30 con- secutively recruited patients who were suffering from depersonalization disorder in order to elucidate the RESULTS phenomenology, associated psychopathology, and treatment history of this disorder. Many of the fully employed dissociative symptoms amnesia, depersonalization, derealization, subjects reported that depersonalization substantially in- identity confusion, and identity alteration on a 4-point severity scale terfered with their capacity to work at a level concordant and diagnoses the various dissociative disorders.
Thus, subjects personalization is sufficiently severe and persistent to cause marked had on average suffered from depersonalization for half distress or dysfunction; and 4 the depersonalization experience is the of their lifetimes.
Mean duration of illness was The remaining 16 tion, amnesia, and self-absorption , which were used in this study.
Post- back as they could remember. Histories of childhood trauma were obtained by the Childhood An- an initially episodic course that later became continu- tecedents Questionnaire 11 , a semistructured interview that rates ous.
Many witnessing domestic violence during each of three developmental pe- subjects described a constant intensity of depersonaliza- riods childhood, latency, and adolescence. The total trauma score tion, while others experienced waxing and waning that ranges from 0 to 9 or higher if there were multiple perpetrators. All three interviewers D. Alleviating factors were tion factor of the Dissociative Experiences Scale for the presence or equally variable: physical stimulation including self- absence of each axis I and axis II disorder.
For the pur- tional impairment that was associated with their deper- pose of data reduction, a principal components factor analysis with varimax rotation was used to extract three factors from all mood, sonalization. The derived factors were scored am so used to it, I cannot remember what it feels like as the raw sum of all variables with loadings greater than 0.
Fi- this. Almost uni- formly, subjects felt that the depersonalization in- Symptom Absent Mild Moderate Severe Mean SD b terfered more with interpersonal relatedness than Amnesia 27 2 1 0 1. Depersonalization 0 0 0 30 4. Four reported a Identity alteration 24 6 0 0 1.
No subject had a history of sei- sia surrounding the treatment but otherwise had no amnesia. The scores for the three factors of the Dissociative Experiences Scale were Three case histories are briefly described. Table 2 shows the content and score Ms. A was a year-old woman who was living with her for each of the six items from the Dissociative Experi- mother and son and worked at a clerical job.
Whatever makes me me is not there. It is like an The mean age of the normal comparison group 14 opaque curtain. The mean score them extremely distressing. She had experienced panic attacks on the Dissociative Experiences Scale for the normal for 1 year when she was 35 and had been diagnosed with comparison subjects was 3.
The two groups suffered from depersonalization disorder since age I am disconnected from my body. All social settings made it much worse. He rected for six comparisons to a significance level of 0. As a child he no disorder significantly differed in age at onset from de- had suffered marked emotional neglect.
His parents fed and personalization disorder. After using the same correc- clothed him but never expressed emotion; he recalled hardly tion, age at onset of depersonalization correlated signifi- ever being touched or kissed.
C was a year-old male performer who had had five sence of any of these six mood and anxiety disorders. The first one occurred at age 14 on the third occasion that he had used LSD.
The second one occurred from past PTSD after a rape at age No subjects at age 21 upon smoking marijuana, which he did very rarely. The third episode occurred 3 years later as he was reading a Axis II comorbidity, summarized in table 4, ran the book about drugs and had felt very frightened by the memory gamut of personality disorders. At had no personality disorder, while the mean number of age 34, Mr.
C again suffered depersonalization, which he felt personality disorders per subject was 1. Of the 18 subjects with personality disor- episode occurred after he looked up depersonalization disor- ders, 10 had personality disorders from multiple clus- der in a medical textbook and discovered a damning descrip- ters, five had disorders only from cluster C, and three tion with little hope of cure. C had been cluster A personality disorders. After Bonferroni cor- suffering from generalized anxiety disorder since age There was no reported child- periences Scale differed significantly only for the hood history of abuse or neglect.
Comorbidity Trauma History Table 3 summarizes lifetime occurrence and current comorbidity of axis I disorders. The most prevalent dis- The mean total trauma score for the 30 subjects with orders were unipolar mood disorders and the various depersonalization disorder was 1.
There was no significant correlation be- tonin reuptake inhibitors and benzodiazepines were re- tween the total or category scores of trauma and the ported as having been of any benefit for depersonaliza- total or factor scores of the Dissociative Experiences tion.
The total benzodiazepines helped their anxiety or panic symp- trauma score of the depersonalization disorder subjects toms but not their depersonalization. The three fac- depersonalization had received ECT, which also re- tors, which were labeled according to clinical content, sulted in no improvement. These three scores and the total trauma score The illness started on average in mid-adolescence, with were then entered into a multiple regression analysis.
The course was usually chronic, waxing and wan- the Dissociative Experiences Scale, they did not signifi- ing in intensity, but was sometimes episodic. Comorbid Treatment History mood, anxiety, and personality disorders were com- mon. The subjects were significantly more traumatized Most subjects had received multiple psychiatric treat- than a matched normal comparison group. Although DSM- a total of 69 adequate dose and duration trials. Al- III-R cites a sex ratio, our finding of a roughly though treatment was not necessarily aimed at deper- ratio of women to men is similar to the two- to four- sonalization symptoms, we retrospectively attempted fold predominance of women in other series 12, It to rate the depersonalization response to all medica- could, however, reflect the bias of women being more tions tried as significantly improved or not.
Only sero- likely to seek evaluation or treatment. This study also con- childhood, and, in fact, about one-fourth of our study curs with the existing impression in the literature that group reported preadolescent onset.
The Dissociative serotonin reuptake inhibitors 30, 31 and possibly ben- Experiences Scale profile of depersonalization disorder zodiazepines 21, 32 may be of some benefit in the is also of interest. Previous analyses have recommended treatment of depersonalization disorder, but prior re- a score of 30 as a cutoff for the detection of dissociative ports of successful treatment with tricyclic antidepres- disorders, which is highly sensitive and specific for the sants 19 , stimulants 13, 15 , barbiturates 2, 33 , or severe dissociative disorders 8 but would often miss neuroleptics 32 were not supported in this study.
Our depersonalization disorder; a lower Dissociative Expe- one subject who had received ECT also did not re- riences Scale cutoff score of 15—20 14 would be more spond, as found in one prior report 16 and in contrast sensitive to the detection of depersonalization. The selective treatment response to The relationship of depersonalization disorder to serotonin reuptake inhibitors, in sharp contrast to tri- mood, anxiety, and personality disorders is an interest- cyclic antidepressants, could have interesting implica- ing and controversial one.
Although chronic, severe de- tions regarding serotonergic dysfunction in depersonal- personalization has been conceptualized as a distinct ization, as has been suggested elsewhere 34,
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