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Depersonalization/derealization – an important & regularly missed diagnosis

The young man sitting in front of me thought he was going mad. I remembered the woman I'd seen who was so frightened of her symptoms that she found it immensely anxiety-provoking to even speak about them. It's not surprising. Of course people suffering from depersonalization/derealization symptoms will try desperately to make sense of what they are experiencing. They will often come to the understandable - but incorrect - conclusion that they must be developing schizophrenia or some other psychotic disorder. Their anxiety about this tends to aggravate the depersonalization symptoms even more, which further worsens their anxiety, and they are caught in a vicious circle. Few health professionals understand or are able to recognize this relatively common disorder. If they are consulted they may well aggravate the poor sufferer's situation even further with inaccurate diagnoses and inappropriate treatments.

The Psychiatric Diagnostic and Statistic Manual (DSM) IV defines Depersonalization Disorder as a feeling of detachment or estrangement from one's self. They comment that it is not uncommon to hear sufferers describe feeling as though they are robots, in a dream, or somehow detached from (even outside of) their bodies. Associated features include derealization (the sense that the external world is strange or unreal), depression, rumination, bodily concerns, anxiety, disturbance in the sense of time, and fears that one is "going crazy". The sufferer is still in touch with reality, but the symptoms are severe enough to cause marked distress.

The Depersonalisation Research Unit at the Institute of Psychiatry in London, is a world leader in this field. Researchers there use the acronym DPAFU (Depersonalisation and Feelings of Unreality) as a shortened label for the disorder. They list four main sets of symptoms that often occur (Sierra, Baker et al. 2005):

1. A sensation of not ‘being there', and of the body moving automatically in a robotic manner. More rarely, people complain of a sensation of being outside their bodies, or feeling as if part of their bodies does not belong to them, or has changed in size or shape.
2. A diminished ability to feel emotions such as feelings of affection towards friends and family, and the ability to enjoy things. Sometimes other emotions such as anger or fear also seem to go numb.
3. A feeling of detachment from personal memories. Sometimes patients complain that their memories seem pale, or say they feel as if what is remembered did not really happen to them. More rarely, people complain of not being able to visualise things in their mind's eye (for example not being able to ‘see' in their minds the faced of a loved one, or he front of their house).
4. Derealisation: a feeling of being cut-off from the surroundings, and that things around look unreal, unfamiliar or changed in a way that cannot be clearly explained.

DPAFU feelings are sometimes induced by alcohol or other drugs, but typically they simply happen on their own. A recent systematic review (Hunter, Sierra et al. 2004) found that about 50% of the population reported occasional symptoms of depersonalization and derealization. Sufferers with other psychological difficulties like panic or depression, are even more likely to suffer from DPAFU as well. The authors concluded "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."

A prevalence rate of 1-2% makes DPAFU more common than Obsessive Compulsive Disorder where two recent surveys have found rates of 0.6 to 1.1% (Crino, Slade et al. 2005; Torres, Prince et al. 2006). Similarly 12 month-prevalence of Panic Disorder is estimated to be about 2.1% and Panic with Agoraphobia at 0.6% (Grant, Hasin et al. 2006). The message is clear - Depersonalization and Derealization symptoms are common, under-recognized and under-treated. There's a huge amount of suffering associated with this disorder that could be helped so much more effectively. I will look at assessment and treatment in a later blog posting.

Crino, R., T. Slade, et al. (2005). "The changing prevalence and severity of obsessive-compulsive disorder criteria from DSM-III to DSM-IV." Am J Psychiatry 162(5): 876-82. [Free Full Text]
Depersonalisation Research Unit, Institute of Psychiatry at the Maudsley, Kings College London. www.iop.kcl.ac.uk/departments/?locator=911&context=main Accessed February 12, 2008.
Grant, B. F., D. S. Hasin, et al. (2006). "The epidemiology of DSM-IV panic disorder and agoraphobia in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions." J Clin Psychiatry 67(3): 363-74. [PubMed]
Hunter, E. C., M. Sierra, et al. (2004). "The epidemiology of depersonalisation and derealisation. A systematic review." Soc Psychiatry Psychiatr Epidemiol 39(1): 9-18. [Abstract/Full Text]
Sierra, M., D. Baker, et al. (2005). "Unpacking the depersonalization syndrome: an exploratory factor analysis on the Cambridge Depersonalization Scale." Psychol Med 35(10): 1523-32. [PubMed]
Torres, A. R., M. J. Prince, et al. (2006). "Obsessive-Compulsive Disorder: Prevalence, Comorbidity, Impact, and Help-Seeking in the British National Psychiatric Morbidity Survey of 2000." Am J Psychiatry 163(11): 1978-1985. [Free Full Text]

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