CASE: Feeling detached
Ms. A, age 23, presents to our clinic complaining of feeling detached for the past 4 years. She says she feels “fuzzy all the time, like I lost touch with reality 4 years ago and really miss it.” She complains of “confused thinking,” excessive tiredness and weakness, depression, and anxiety. She says, “It feels like I’m watching my life on television; I don’t feel any emotions.” These symptoms began immediately after a college party, which the police stopped because of underage drinking. She says, “I don’t know why, but that party set it off, and it feels like I am in a dream all the time.”
For the last 4 years, Ms. A has been working as a waitress and is now engaged. She presents to our clinic because the treatments she has been receiving are ineffective and she wants to feel her emotions again, especially before her wedding.
Ms. A has no history of mania, depression, or psychosis. She says she was an anxious child and suffered from anorexia nervosa between age 13 and 14. She experienced occasional panic attacks beginning in high school that were triggered by feeling overwhelmed or frustrated with not feeling normal. During these panic attacks, Ms. A experienced tightness in her chest and dizziness. She denies suicidal or homicidal ideation or attempts.
At age 18, she was sexually assaulted. Ongoing stressors include living in a dangerous neighborhood, having her car broken into, her father’s disapproval of her fiancé, and wanting to get married. She drank heavily in college, but has used alcohol infrequently since then.
Ms. A’s father has a history of anxiety. She describes him as domineering and her mother as very emotional and always wanting to be her friend. Ms. A says she struggles with relationships, employment, and plans for advancement, all of which are moderately to severely affected by her depersonalization symptoms. During the initial appointment, we diagnose Ms. A with generalized anxiety disorder, panic disorder, and major depressive disorder (MDD).
Which diagnoses would you include among the differential diagnosis?
- posttraumatic stress disorder (PTSD)
- MDD with psychotic features
- depersonalization disorder
- schizophrenia, undifferentiated type
- psychosis not otherwise specified
The authors’ observations
Depersonalization symptoms can occur in a variety of situations, including:
- mentally healthy persons suffering from acute stressors, fatigue, or drug use
- neuropsychiatric conditions such as epilepsy
- migraine
- anxiety disorders
- depressive disorders
- schizophrenia.1
Transient depersonalization symptoms are common and have been found in 2.4% of the general population.2 Community surveys using standardized diagnostic interviews reveal 1-month prevalence rates of 1.6% to 1.9% in 2 UK samples.3,4 Depersonalization symptoms are brief and less debilitating than depersonalization disorder.
Depersonalization rarely presents as a primary disorder, when symptoms persist chronically. Rating scales (Table 1)5-7 and DSM-IV-TR criteria (Table 2) can help assess symptom severity and differentiate transient symptoms from a disorder. Psychiatric conditions that commonly are comorbid with depersonalization disorder appear in Table 3.8 Triggers for a first episode of depersonalization disorder include:
Table 1
Assessing for depersonalization: 3 rating scales
| Scale | Description |
|---|---|
| Cambridge Depersonalization Scale5 | 29-item, self-report questionnaire meant to capture frequency and duration of depersonalization symptoms over the previous 6 months |
| Depersonalization Severity Scale6 | Covers a range of axis I and II psychopathology |
| Dissociative Experiences Scale7 | 28-item, self-report instrument to measure dissociation |
- psychological stressors (31%)
- substance abuse (25%)
- physical stressor (12%)
- situational stressor (17%)
- social and/or relationship problems (10%)
- trauma (6%)
- panic/anxiety (2%).8
Although Ms. A experiences depersonalization—constant numbness and emptiness—when she thinks about the sexual assault, she does not meet criteria for PTSD because she denies re-experiencing the assault, hyperarousal, and avoidance behaviors.
Ms. A meets all 4 DSM-IV-TR criteria for depersonalization disorder (Table 2). She experiences persistent feelings of detachment, which cause her considerable distress. Her reality testing is intact and these experiences are not due to a general medical condition, another mental disorder, or direct physiological effects of a substance.
Table 2
DSM-IV-TR criteria for depersonalization disorder
| A. Persistent and recurrent experiences of feeling detached from oneself and as if one is an outside observer of one’s mental processes or body. B. During the depersonalization experience, reality testing remains intact. C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another dissociative disorder, and is not due to the direct physiological effects of a substance (eg, a drug of abuse or a medication) or a general medical condition (eg, temporal lobe epilepsy). |
| Source: Diagnostic and statistical manual of mental disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association; 2004 |