'Feeling Unreal: Depersonalization Disorder and the Loss of the Self' by Daphne Simeon, MD, & Jeffrey Abugel
Depersonalization, the experience of feeling disconnected from one’s sense of self, is a common symptom associated with PTSD and trauma. In fact, it’s so common that in the DSM-5 it is included, along with the closely related symptom of derealization, in the criteria for an Acute Stress Disorder and as a specifier for PTSD. For PTSD, the DSM-5 describes depersonalization as “Persistent or recurrent experiences of feeling detached from, and as if one were an outside observer of, one’s mental processes or body (e.g., feeling as though one were in a dream; feeling a sense of unreality of self or body or of time moving slowly).”
Despite the frequency with which depersonalization is reported clinically, I have read very little on the topic, so I was excited when I read the title of this book. The book is written by Daphne Simeon, MD, who is a psychiatrist, and Jeffrey Abugel, a journalist who experienced depersonalization himself over the course of 10 years. They start the book by explaining what depersonalization is and then review theories that have informed our understanding of Depersonalization Disorder over the past century looking at psychological theories, physiological theories, and cultural influences.
They list two main clusters of symptoms have been described in Depersonalization Disorder over the past century. The core symptoms which are the most frequently reported include:
altered body experience
feeling a loss of agency
subjective memory complaints.
The second cluster of symptoms includes feeling an emptiness of the mind, heightened self-observation, distortions in one’s sense of time, and a feeling of things being ‘unreal’.
One of the first theories presented is from Pierre Janet who wrote that psychic activity is composed of primary and secondary components. Primary relates to psychic activity elicited by external stimuli, whereas secondary psychic activity runs in the background giving context and meaning to primary experiences. If the two become disconnected, then a feeling of depersonalization can arise. A number of other theories followed over the next century which they describe succinctly and clearly.
In the book, they discuss two studies, one in the U.S. and the other in the U.K., looking at 300 people with Depersonalization Disorder in the 1990’s, and the following findings are described:
The average age of onset is in adolescence
Men and women are equally affected
Onset can be either acute or insidious
It is typically chronic, constant and unremitting.
It frequently overlaps with mood and anxiety disorders.
Common triggers are severe stress, episodes of other mental illness, and drug use.
Emotional maltreatment in childhood is associated with the disorder and its severity.
We do need to keep in mind that this book was published in 2006 so there may be new research in the field which I haven’t had time to review. Simeon is a prolific researcher with a lot of papers and book chapters on this topic so google her website if you want more info.
The authors go on to then reflect on an interesting question; is depersonalization reflective of a state of hyperarousal or hypoarousal? Prior to reading this book I would have felt inclined towards the hypo-aroused state; however, the authors do a great job of describing the anxiety that is experienced by many with depersonalization. Not surprisingly, ruminating over the experience of depersonalization can enhance anxiety and this can sometimes escalate to an obsessive level of focus. The authors write that perhaps it’s less about poles of arousal and more about abrupt or large shifts in arousal states, or a mismatch between perceived stress and physiological arousal. Whatever the case, the authors note that grounding and other skills can often be personalized to the person based on the prominence of hyper or hypoarousal states.
This book was helpful to read in that it covers a lot of ground by discussing case examples, theories, philosophies, neurobiology, and treatment options related to depersonalization. For many with histories of repetitive, childhood trauma, the concept and experience of ‘the self’ is already fraught and complex. Reading this book leaves me reflecting on the complexity of working on understanding and nurturing a sense of self in therapy when one is also feeling disconnected from self, 'unreal', and without a sense of agency.
Thanks for reading! - Dana