The phenomenon of depersonalization
Depersonalization can hit like a clap of thunder; in a split second all tilts towards the surreal and the trusted sense of reality evaporates. It can seep in insidiously, settling in for relentless decades of profound estrangement and detachment. Some are propelled in and out of transient episodes in response to triggering events, and some actually willfully induce states of depersonalization to avoid the claws of unacceptable reality (Guralnik, 2008).
Phenomenologically people describe witnessing their lives as if it were a movie or “from the ceiling”, an experience often accompanied by a bitter deadening of affect: “The emotional part of my brain is dead… My laugh is automatic; there just doesn’t seem to be anything there…” (Patient reports, Mt Sinai - PRMS). The integrity of time, space, mind and body falls apart: “The times have gone… Everything around me is very far away and tiny…” (Shovron, 1946), “I enter the house I lived in for the past 7 years and feel like I’ve never seen it before… I look at my hand and it does not belong to me, it looks large and foreign…” (PRMS). The unity of intention and action fragments: “I can hear my voice talking, but it does not seem to be coming from me…“ (PRMS). The result of these various fragmentations is that for the depersonalized what used to be implicitly relied on as “me” and “reality” is pulled from under, leaving one de-clothed of a familiar self, in an alienated landscape.
Although prevalent[2], depersonalization is poorly studied and unfamiliar to even seasoned clinicians. It is a subjectively felt altered state of consciousness, not an affect or a disturbance of thought, yet the actual ‘symptoms’ are terribly difficult to describe. It infects a rather abstract psychological register in which one draws conclusions, grounds and narrates what their Self, and ultimately Reality, mean to them[3] (we will return to this register in later sections). When mentioned in the literature, depersonalization typically gets incorporated into existing categories and misattributed as an epiphenomenon of more familiar disorders of affect such as depression and anxiety. The implication is that depersonalization cannot be engaged with directly but will somehow lift when other problems clear. Indeed, people with relentless depersonalization typically grow increasingly alienated and hopeless after migrating from one mental health professional to the next, misdiagnosed, misunderstood and treated with no success.
As far as definitions, depersonalization should be distinguished from the concepts of dissociation and repression. As a diagnostic category depersonalization is classified by the DSM-IV-TR (2000) as one of four primary dissociative disorders. All four come under the roof of dissociation because they share the mental operation of splitting apart and excluding from consciousness psychic materials that are typically integrated into one experience (self-states or ‘identities’ in Dissociative Identity Disorder, a renounced self in Fugue, auto-biographical memories in Amnesia, personhood and real-hood in Depersonalization and Derealization). Thus, depersonalization is a sub-type of dissociation. Often when clinicians refer to their patients’ dissociation they are actually describing the very specific experience of depersonalization.
As dynamic psychic mechanisms both dissociation and repression are ways to banish mental contents from consciousness. They have different implications regarding psychic structure and dynamics. In repression the hidden elements are thing-representations of particular contents. In dissociation they are structures, potential ways of being a person in the world. Repression disallows conscious representation of once-known, anxiety provoking “things” like memories, wishes and fantasies. Under the supervision of the ego’s censor, neurotic distortion renders these thing-representations unavailable to the conscious mind. Dissociation, in contrast, segregates or de-links “states” rather than things, matrixes of self-other-relationships and their related affects[4]. The parallel operator to the repressive censor in the case of dissociation would be avoidance of attending-to and formulating into meaning (Stern, 2007). As a sub-category of the ability ‘to dissociate’ one also has the capacity ‘to depersonalize’, whereby one becomes detached and certain aspects of self become inarticulate or unavailable, instigating the subjective dis-ease of depersonalization.
Much of the thinking collected here is based on a series of NIH and NARSAD-funded studies of the phenomenology, etiology, cognitive processes, biological correlates and treatment of depersonalization. These were conducted over eight years by a research group we founded at the Mount Sinai School of Medicine in New York City (Director: DS) with more than 350 patients for whom depersonalization was the primary symptom. Our main findings are summarized in a selection of our papers: Simeon et al., 1997, 1998, 2000, 2001a , 2001 b, 2002, 2003a, 2003 b; Guralnik et al., 2000, 2007).