Depersonalization Disorder Study

Sarah OBrien Spring 2011

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To the brain, one second is a lot of time. Its enough time, to tell the heart to beat again, the diaphragm to contract, the intestines to keep processing the food in them, the eyes to blink, all while this person walks, smiles, listens, and thinks about complex ideas. In this instant, the brain also has the ability to drastically alter ones perception of the world. The familiarity of both the inner and outer worlds is suddenly lost. The previously held frame of understanding for ones stream of senses is confused. Things seem far away and somehow wrong. Ones basic sense of self is suddenly disconnected, perhaps known but not felt, perhaps not even known. Everything is passing by; leaving the sufferer untouched. Known by name to too few, this experience is called depersonalization. Depersonalization has been determined as the third most common clinical symptom after depression and anxiety (Sierra 201, 44), and between 1% and 2% of the population experience it chronically, known as depersonalization disorder (Simeon & Abugel, 87). Despite this prevalence, depersonalization has had a hard time gaining acceptance and recognition from the medical community. Why? There are a few answers, none of them particularly satisfying. The authors hope in writing this is that awareness about depersonalization disorder might reach people beyond the medical professionals. Everyone experiences and thus describes depersonalization a little differently. The words Jeffery Abugel found were his "Nine Circles" (Abugel 25-32); others describe it as a glass wall, a veil, being a zombie or a robot; these are all valid perceptions. Its defining characteristics in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are a feeling of detachment or estrangement from ones self There may be a sensation of being an outside observer of ones thought processes, ones body, or parts of ones body. Various types of sensory anesthesia, lack of affective response, and a sensation of

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lacking control of ones actions, including speech, are often present. The individual with Depersonalization Disorder maintains intact reality testing (e.g.) awareness that it is only a feeling and that he or she is not really an automaton) (Simeon & Abugel 13). These experiences only qualify as depersonalization disorder if they are persistent/severe enough to cause marked distress or impairment in functioning (Simeon & Abugel 13). Hopefully the upcoming symptomology will make more sense when related to an anecdote of depersonalization from the inside. An experience of depersonalization disorder might sound something like this: "I looked around and everything seemed different, like nothing was real, like I was in a dream or a movie or under the influence of drugs. An unbelievably hot rush of fear swept through my body (my doctor tells me it was panic) and I headed straight for the toilet. I tried to shake it off but I couldn't, then it hit me, either one of my workmates had spiked my lunch or I was going nuts and would surely be committed. Even the thoughts in my head seemed somehow askew The only way I could describe it to my GP, family, and friends was a feeling of "displacement." I compared it to the feeling of when you're suddenly awakened from sleep by a ringing phone. You fumble around, neither awake nor asleep So I went back to work, but there was this weird thing with my perception, like a haze in my brain. My vision was clear but something about it was blurry, as if I were looking through someone else's eyes. I have never been the same since During the year DP didn't stop me from doing anything, I traveled, socialized, drove and skied. I had no Agoraphobia and I didn't feel overly

Depersonalization Disorder Study anxious, but no matter what I did it wasn't the same as before, nothing

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looked the same and nothing felt the same. I was the walking dead, like I was no longer a part of the world; in it, but somehow not part of it. Everything seemed surreal, with a feeling of displacement as if I was in a dream or trance, an altered state of consciousness I feel that my brain is slow to interpret visual images, and changes in light. For example, if I'm sitting in a room doing whatever, and then I get up and walk to another room, the new setting throws me When I'm outside on a sunny day and drifting clouds block the sun, the sudden change in light makes me feel strange for a minute until I get used to it I endured a constant awareness of self-awareness, and an inability to concentrate and focus. I felt physically weak I honestly thought that whatever it was, it would go away just as quick as it had come to me. I maintained my social life and did the things I always did for fun, but it wasn't the same, it wasn't fun. I couldn't feel anything. Sometimes I thought I may be dead and not know it, and sometimes when talking to people I would think to myself, did he just say that or did I imagine it?" (Abugel 66-68) From this anecdote, let's take as many symptoms of depersonalization to the clinical level as we can. The speaker above described feeling as though he were not part of the world, feeling displaced. This fits into a category of symptoms called "Changes in body experience" (Simeon & Abugel 69), referring to a range of alterations to the depersonalized patient's experience of himself. These alterations include the perception of

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one's body as not belonging to oneself, while being aware of the falseness of this assessment; a sense of 'loss of agency' (Sierra 29) wherein the depersonalized patient describes feeling like a zombie or automaton, as though despite his conscious state, he is not the one controlling his actions; a sense of disembodiment (Sierra 30); and last, selfobservation or self-focus, which can be experienced as one's mind or thoughts being somewhere entirely other than the body, or as a mental split between an "observing self" and an "experiencing self" (Sacco 30). Compared to anomalous body experiences, the other symptom categories have fewer facets. Much more straightforward is the experience of emotional numbing. As the speaker describes, despite his continued efforts to live a normal life, he couldn't seem to evoke any emotional response from himself. From the clinical research, it appears that this lack of emotional response is more a lack of ability to physiologically experience an emotional reaction than it is a lack of cognitive understanding of the situation, or how one expects to react to something. Furthermore, this lack of ability to emotionally color a place or experience contributes to the depersonalized perception of unreality (Sierra 32). Slightly broader in scope are the "anomalies in subjective recall" (Sierra 33). According to Sierra, the memory loss experienced under depersonalization is not total amnesia, but rather a separation between knowing that something happened, and knowing that it happened in reality and not just in a dream or one's imagination, as described in the anecdote (Sierra 34). Depersonalized patients "were found to have a significant impairment" compared to a control group when tested on the vividness of visual imagery (Sierra 35). In the experience of time, depersonalized patients often feel as though recent events occurred much longer ago. Again, we have a discrepancy between the knowledge

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of something and the experience of it under depersonalization. Other noted distortions include one's sense of duration (how the speed of one's internal clock matches or doesn't with geophysical time) and ones sense of time continuity, where linearity may be replaced with discontinuity. Also fitting under this category is the sense of an empty mind. Literally, depersonalized patients may feel as though they have no thoughts; this has been related to the ability to direct ones attention, and that such attentional deficits would have deleterious effects on the short-term memory system (Sierra 38). The last and most important of the symptoms is derealization. Derealization and depersonalization are so similar that some argue they are the same thing, simply seen from different perspectives. The distinguishing sense of unreality and estrangement in depersonalization comes from the symptom of derealization, often described as seeing through a fog, a pane of glass, a veil, etc. In his article on depersonalization and the circumplex model of emotions, Sacco proposed that the split between the observing and experiencing self is what distinguishes depersonalization from derealization, as the latter appears to be a transient alteration of consciousness with no dissociation between an observing and experiencing self (Sacco 33).

So if those symptoms are some kind of end result, what causes it? Unfortunately, there isnt one solid answer. Certain triggers have been identified, but it isnt entirely clear how those things work. There is a significant amount of people whose chronic depersonalization was drug-induced. In these cases, the onset of depersonalization generally required only one instance, not repeated drug use, and occurred in the use of psychoactives such as cannabis, LSD, ecstasy, ketamine, and to a lesser degree,

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psilocybin mushrooms (Medford et al. 1732). In addition, some experienced emotional or physical abuse as an immediate trigger; others were affected years later (Steinberg & Schnall 61). In the case of repression, it can indeed develop years after the trauma author Marlene Steinberg & Schnall uses the metaphor of a closet that has already been filled with the emotions and memories of a traumatic event; when a new stressor or reminder occurs, shoving those feelings into the already full closet results in everything tumbling out now, years after the fact (Steinberg & Schnall 257). Additionally, extremely stressful events or situations are known to trigger chronic depersonalization (Sacco 3031). Interestingly enough, the onset of depersonalization does not reportedly come at the peak of the stress for these people, but rather after the stress has resolved (Sierra 45). But for some people, depersonalization disorder has no observable trigger- they have no history of abuse, do not associate the onset with drug use, and did not begin to experience it around a high-stress period of time. The above suggests that though there may be a psychological component to depersonalization, there is always an underlying, primary neurobiological component in its chronic form. As researchers work to find a pharmaceutical treatment for depersonalization, they explore this neurobiology. Thus far, though, the mechanism by which depersonalization is triggered (if there is a single mechanism) remains unclear, and there are several potential pathways currently being researched and explored which may be at least peripherally involved. Because of the variable ways in which depersonalization can present itself, its comorbidity (or simultaneous presence) with other disorders, and its ineffability, diagnosis is difficult. As the reader will recall, symptoms ranged from emotional numbing to

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perceptual alterations (especially visual), to poorer short-term memory and attentional deficits, to an altered sense of time. These disparate symptoms all have a link: ones sense of self. Despite the cohesive loss of reality that depersonalized patients experience, the functions that control these symptoms are scattered across different parts of the brain. To start, lets look at what different parts of the brain do. There are four main lobes that make up the cerebral cortex (or outermost layer of the brain): the frontal, temporal, parietal, and occipital lobes. The frontal lobe deals with decision-making, perceiving potential consequences of ones actions, suppressing unwanted or unacceptable behavior, and some short-term memory processes. The temporal lobes deal with emotion, memory, meaning, and sound processing. The parietal lobe processes and integrates somatosensory information coming in from the body and also works with numbers to some extent. The occipital lobe deals with sight and visual processing, and is believed to be the part of the brain responsible for dreams. Additionally, inside the cerebral cortex is the limbic system. This area is related to emotions and different autonomic functions, and has strong links to the pleasure centers of the brain and prefrontal cortex. Given this basic information, the reader can see how the symptoms of depersonalization do not fit into one easily labeled, curable box. All four lobes have depersonalization-related functions, but if they are all involved, how can there be one answer? Examining the potential answers thus far, there isnt. Today, the most prevalent theory is that depersonalization results from the right ventrolateral prefrontal cortex acting upon the insula, a part of the limbic system (Sierra 136-37). Essentially, this part of the prefrontal cortex becomes overactive and in doing so

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suppresses activity in the insula. What does this mean? The right ventrolateral prefrontal cortex has been implicated in the evaluation of negative or aversive information, and on exerting control over both emotional experience and its impact on decision-making (Sierra 137), whereas the insula is thought to be crucial to making conscious ones emotional (anterior insula) and embodiment/self-awareness (posterior insula) feelings (Sierra 145). Another common model is that of cortico-limbic dysconnectivity. As in the first model, the over-activated prefrontal cortex inhibits the limbic systems activity, altering the emotional component of what one is experiencing (Simeon & Abugel 111). One researcher who worked mostly with PTSD patients suggested that for depersonalized patients, cortico-limbic dysconnectivity existed alongside multiple other types of dysconnectivity- between areas of the cortex, and between the cortex and the thalamus, which is responsible for relaying and modulating incoming perceptions from the outside world via our sensory organs (Simeon & Abugel 112). As modern medicine focuses on mental health treatment via the chemicals of the brain, there is discussion of which neurotransmitters are involved in depersonalization as well. Of course, treatment does not always focus on the problem chemicals, but rather on using what medications are already available; therefore, some of the discussion of biochemistry will be in the section on pharmacological treatment and not here. Biochemicals hypothesized to be involved in depersonalization in some way or other are the opioid system, cortisol, norepinephrine, and glutamate. The neurotransmitter responsible for connections between the cortical pathways mentioned in the previous paragraph is glutamate, and its receptor is the NMDA receptor (Simeon 112). As the

Depersonalization Disorder Study reader will recall, one of the drugs listed that is associated with the onset of

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depersonalization is ketamine- and ketamine blocks the NMDA receptor. The opioid systems role is the regulation of emotional and behavioural responses to stress (Cohen et al., 1983) and so activating this system in a stressful situation (like the ones that bring on depersonalization) in order to overcome those stressors could be viewed as beneficial (Sierra 117). Then, the stress hormone cortisol may or may not have an influence on depersonalization. Some studies have found that depersonalized patients have lower levels of plasma cortisol compared to depressed patients, but not normal controls (Sierra 139). Others found that when using dexamethasone to suppress the test subjects production of cortisol, suppression was least successful in the depersonalized group, even though the depersonalization group and control group had the same results for a 24-hour urinary test for cortisol (Sierra 139). There is no solid explanation for this, but it does appear that cortisol is peripherally involved with depersonalization. All these models and aspects discussed above have some degree of plausibility, and are not necessarily mutually exclusive. It is also worth acknowledging that without a way to employ this information, the majority of it becomes a broken crutch, upon which no weight/forward motion can be rested. At this point, the depersonalized patient may easily be better served by moving forward with coping strategies than by dwelling on the how or why reductions of self. That said, the main point that can be drawn from the research is that more research is needed.

Though exploring the physical basis and treatment of depersonalization is necessary to understanding anything about the disorder, there is much that helps in

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painting a fuller picture of the person suffering from depersonalization in looking at its comorbidity, or simultaneous presence alongside other disorders, and its cultural aspects. Of the personality disorders, the three highest-ranked for comorbidity with depersonalization were avoidant at 23%, borderline at 21% and obsessive-compulsive, also at 21% (Simeon & Abugel 102). People with avoidant personality disorder tend to have heightened self-awareness, especially in social situations, and are generally shy/avoid social situations; people with BPD have a poorly-formed sense of identity/self, are prone to extreme moodiness, view things exclusively in absolutes or extremes, , and tend toward impulsivity and risky behaviors; and people suffering from OCPD are very perfectionistic, rigid, and controlling. In small studies done on the comorbidity of depersonalization with mood and anxiety disorders, people with both depression and anxiety disorders experienced depersonalization quite commonly- panic disorders more commonly than depressive, [suggesting] that both depression and anxiety can exacerbate depersonalization and make it more intense (Simeon & Abugel 101). Furthermore, there appears to be little to no relevance between PTSD and depersonalization disorder. Simeon hypothesizes this is related to the magnitude and quality of the trauma experience in PTSD as opposed to DPD (Simeon & Abugel 101). Interestingly enough, depersonalization has definite cultural correlations. For example, it has been reported that the prevalence of DSM IV or ICD-10 dissociative disorders seems so low amongst Indian psychiatric in-patients as to cast doubt on the clinical relevance of this diagnostic category in India (Sierra 101). Depersonalization appears to be rarer in Asian and Latin American countries as compared to Western Europe and North America (Sierra 103). The author attributes this to cultures of

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collectivism versus individualism, respectively; in a more collectivist culture, the self is a much more interdependent and relational being, where in an individualist culture, the self is seen as independent, standing alone and self-reliant. It follows logically that the difference in how the self is seen between these two cultures may very well contribute to the perceptions and attitudes that allow depersonalization to occur. There is evidence supporting the strength of influence on cognition and emotions held by the individualism or collectivism of ones culture (Sierra 103). Further research found a high correlation between individualized culture/attitudes and a fear of losing control (Sierra 106). It is believed that the experience of panic can indeed be a mediating mechanism capable of triggering dissociative responses during acute trauma (Sierra 107). The role of the internet in modern society could also potentially influence depersonalization. Internet use varies culturally; however, the internet is also relevant to de-personalization by putting a middleman in the interactions of internet users. The globalization and anonymity this provides is a double-edged sword; people who otherwise would never have connected have an opportunity to do so, but those who could connect in real life now have valid options other than the level of authenticity, connection, and health found in physical human interaction. Relating this to depersonalization disorder specifically, it has been shown that artificial lighting increases feelings of depersonalization (Simeon & Abugel 21). And though the internet provides easy access to a wealth of knowledge there is a great difference between knowing and understanding Another way of putting the point is that no amount of access to data will in itself develop any child into Peter Sheldrakes effective functioning member of society

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(Laura et al. 55). The point about knowing versus understanding has been made previously as it relates to depersonalization. Depersonalized people often have difficulty with the know/remember components of an experience. While their declarative memory of an event remains relatively untouched, they may not feel as though it happened to them. Also, though today we may consider the way to a meaningful connection with another person very implicit, its worth asking whether the increased ubiquity of the internet (and other technology) in our interactions could unhealthily alter the way people learn to relate to each other, and foster depersonalizing environments. In summary, the confluence of various personal, technological, and cultural conditions in each individual has a profound effect on the appearance of depersonalization, as a disorder or otherwise. The examination of these and other fundamental aspects of living today sheds light not only on the whole depersonalized person, but also on how others might better understand and improve their environment (and themselves) for optimum presence in the moment.

As mentioned previously, there is a limited array of therapy, both psychopharmacological and psychological. Depersonalization is considered refractory to pharmacological intervention and its erratic responsiveness contributes to the mystery of depersonalizations neurobiology/neurochemistry (Philips et al. 3). The SSRI fluoxetine, for example, was found in one study to be ineffective in treating depersonalization symptoms, but the patients reported their symptoms feeling less bothersome (Simeon et al. 4). Benzodiazepines are used to treat the anxiety that occurs alongside depersonalization or can trigger the depersonalization, though ironically, a potential side

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effect of withdrawal with the benzodiazepine class is depersonalization/derealization (Neziroglu & Donnelly 151). Opioid antagonists naltrexone and naloxone combat depersonalization through the opioid system, responsible for sending out numbing chemicals during stressful situations so that functioning is not impaired by stress. There have been a few very small-scale trials done of opioid antagonists on depersonalized patients with relatively successful outcomes, a few patients experiencing complete and lasting remission of depersonalization, but more research is needed (Sierra 119). Little research has been done on depersonalization up to this point as compared to the depression and anxiety spectrum disorders, and so more research into depersonalizationspecific treatments, whether pharmaceutical, supplementary or otherwise, is needed. Even less researched are valid psychotherapeutic approaches to depersonalization. There have been studies done on the effects of cognitive-behavioral therapy and little else (Simeon 2004, 352). However, not everyone interested in treating depersonalization goes the research route. Fugen Neziroglu and Katharine Donnelly wrote the book Overcoming Depersonalization Disorder: A Mindfulness & Acceptance Guide to Conquering Feelings of Numbness & Unreality for sufferers of depersonalization rather than medical professionals (Neziroglu & Donnelly 2010). In it, they explore the application of acceptance & commitment therapy (ACT), dialectical-behavior therapy (DBT), and mindfulness-based cognitive therapy (MBCT) to depersonalization disorder of these, ACT is the therapy of focus. ACTs premise as it relates to depersonalization is to not allow symptoms of depersonalization to influence the choices one makes, and in doing so, increasing tolerance for those feelings and ultimately forcing ones brain to be the one to make an adjustment. Additionally, this therapy puts the emphasis on action

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(particularly presencing oneself) rather than trying to think things out. Because of depersonalizations connection to anxiety and the tendency to self-focus, this mode of thought can do more to paralyze the person in their own thoughts than lead to any meaningful conclusion. Though there isnt any clinical information on which therapies have the most successful outcomes, ACT and MBCT certainly have the most specific relevance and application to depersonalization out of the therapies discussed.

Having laid out what is known of depersonalization from a strictly medical perspective, we can now explore other aspects of this enigmatic disorder. Depersonalization appears to have a place in literature, philosophy, and even spiritual experiences. Descriptions of depersonalized states (detachment, estrangement, as well as a heightened awareness of the infinite and eternal) are additionally found in common works from the Bible, to Shakespeare, to Dostoevsky, to modern pop lyrics (Simeon & Abugel 128). These perspectives do much to enrich ones comprehension (or experience) of what is otherwise relegated to a stigmatized mental disorder that some clinicians still believe is a symptom, not even a disorder in its own right- or do not even know. Perhaps the most famous of these appearances of depersonalization outside clinical literature is existentialist Jean-Paul Sartres book Nausea (Sartre 2007). Through the eyes of character Antoine Roquentin, the reader observes a world which does not touch Roquentin, though he moves through it, observing it (and himself) and recording it in his diary (the book). Sartre writes compellingly: It is the reflection of my face. Often in these lost days I study it. I can understand nothing of this face. The faces of others have some sense,

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some direction. Not mine. I cannot even decide whether it is handsome or ugly When I was little, my Aunt Bigeois told me If you look at yourself too long in the mirror, youll see a monkey. I must have looked at myself even longer than that: what I see is well below the monkey, on the fringe of the vegetable world, at the level of the jellyfish. It is alive, I cant say it isnt; but this was not the life that Anny contemplated I would like to take hold of myself: an acute, vivid sensation would deliver me. I plaster my left hand against my cheek, I pull the skin; I grimace at myself. An entire half of my face yields, the left half of the mouth twists and swells, uncovering a tooth, the eye opens on a white globe, on pink, bleeding flesh. That is not what I was looking for: nothing strong, nothing new; soft, flaccid, stale! (Sartre 17) Whether Sartres voice in this book is due to immersion in existentialist philosophy, or actual experience of depersonalization/derealization, is not known. Whatever the case may be, his writing is evocative of the estrangement from self and world experienced in depersonalization. This also raises the point that depersonalization, marked by rumination as it sometimes is, could potentially be brought on by such ruminations- a willful perceptual change, as in the case of someone delving into existentialist philosophies- or, perhaps, it could be argued that those who would delve into existentialist ruminations had some level of predisposition towards such thoughts, just as it is theorized that some people have some inherent predisposition for depersonalization.

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In the realm of spiritual experiences, exploration takes on a slightly different form, if not intent. The clearest parallel between depersonalization and any spiritual experience is found in the beliefs of Buddhism. In Buddhist teachings, depersonalization is actually a desired state, called anatta or no-self. According to these teachings, the physical/mental senses are not actually part of the self or I in any way. In fact, author Suzanne Segal wrote a book detailing her life under depersonalization, called Collisions with the Infinite, and after it was published she began receiving letters of congratulations from spiritual teachers from around the world (Simeon 2010, 145). Cultural exposures are especially relevant here. Someone who knew of Buddhism might be able to see their condition in a different light and discuss it in a way that gives the state meaning and value. Additionally, classic psychologist William James wrote the text The Varieties of Religious Experience, which focuses much more on early 20th century firsthand Christian accounts of encounters with God (James 1997). In relating experiences of God to a frame of experience understandable by the nonreligious, he writes, our whole higher prudential and moral life is based on the fact that material sensations actually present may have a weaker influence on our action than ideas of remoter facts (James 59). It describes a state similar to depersonalization, where the present does not feel quite as present as other aspects of existence. In James lecture The Sick Soul, one mans recollection of a state of nervous exhaustion shares many similarities with descriptions given of the immediate, awful onset of depersonalization, from the universal terror that jolted him awake one night, to the unreality and emotional deadening he described as

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something like the suffering of hell every idea of heaven was taken away from me: I could no longer conceive anything of the sort. Heaven did not seem to me worth going to. It was like a vacuum; a mythological Elysium, an abode of shadows less real than the earth. I could conceive no joy, no pleasure in inhabiting it. Happiness, joy, light, affection, love- all these words were now devoid of sense. Without doubt I could still have talked of all these things, but I had become incapable of feeling anything in them, of understanding anything about them (James 128)

Similarly unalleviated states akin to depersonalization appear in The Divided Self, and the Process of Its Unification. James mentions something called the twiceborn character, whose psychological basis seems to be a certain discordancy or heterogeneity in the native temperament of the subject, an incompletely unified moral and intellectual constitution not unlike the lack of integration between different views or beliefs that can contribute to depersonalization (James 144). Indeed, in the same breath he cites a man who felt he had two selves: Oh, this terrible second me, always seated whilst the other is on foot, acting, living suffering, bestirring itself. This second me that I have never been able to intoxicate, to make shed tears, or put to sleep. And how it sees into things, and how it mocks! (James 144) This description lines up perfectly with what clinical literature has labeled the observing and the experiencing self in depersonalization.

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Despite its relative obscurity, depersonalization is very understandable, especially when taken from a human viewpoint rather than a clinical one. Dissociation is a means of removing oneself mentally from a stressful, traumatic, or otherwise overwhelming situation when physical removal may not be possible. And too, we are taught as a society to live more in our heads and our thoughts and futures and the things surrounding us than to be embodied, to be (aware of the) present. In the spectrum of human existence, of course some people will find that their brains oblige their desire to not be here a little too well. If nothing else, let this be a reflection of greater patterns than one mental disorder. On the one hand, some can find a viewpoint from which they thrive on depersonalization, spiritually or otherwise; on the other, ones inability to shape depersonalization to the expectations that are placed on that person (from within and without) can cause the existing divide within the self to widen. As attention is drawn to depersonalization and further research is done, there is more hope for sufferers every day. Online forums for depersonalization offer an avenue for understanding and discussion between people who are personally dealing with this disorder. And by choosing to be present and aware, both in our own lives and in witness to depersonalization, we combat the roots of that disconnection.

References

Abugel, J. (2010). Stranger to my self: Inside depersonalization: the hidden epidemic. Carson, VA: Johns Road Publishing.

Journalist Jeffery Abugel, who dealt with depersonalization disorder for ten years, wrote this book on it. Compared to more clinical or legitimized texts, he includes some of the same information, but is more comprehensive, interdisciplinary, and human than such authors in his research. He includes sections on neurobiology and treatment, but surrounds them with case studies and anecdotes that serve to clarify and give insight. He connects depersonalization to different aspects of culture- certain art movements, existential philosophy, and spiritual/religious traditions. This book has some incredibly unique, useful highlights. No other author takes the same consideration for cultural contexts of depersonalization, and Abugel is very thorough in this. Additionally, it is useful to me to see someone writing about the neurobiology of depersonalization for a lay audience.

Hunter, E. M., Sierra, M. M., & David, A. S. (2004). The epidemiology of depersonalisation and derealisation: A systematic review. Social Psychiatry & Psychiatric Epidemiology, 39(1), 9-18. Retrieved from EBSCOhost.

This article examines DP/DRs epidemiology, or prevalence in the general population as has been studied. This entailed reviewing various databases and citations

for relevant information and studies, and compiling it all in this paper. The authors found that transient DP/DR has a lifetime prevalence rate of 26-74%, increasing to 31-66% around the time of a traumatic event. This and other various results for certain populations suggest that DP/DR are definitely common enough in many populations to merit more awareness, acceptance, and research. This study is extremely relevant to my work. Part of the reason why anyone should read about depersonalization is its widespread existence in many forms and places. The specific statistics of different populations contained herein are strong evidences for DP/DRs relevance that I can link back to.

James, W. (1997). The varieties of religious experience. New York, NY: Touchstone.

Psychologist William James delivered the lectures that make up each chapter of this book more than a hundred years ago. He takes a philosophical approach to examining each of the firsthand accounts that comprise the centerpieces of each discussion, grounding his arguments in his psychology background. Topics include The Reality of the Unseen, The Sick Soul, The Divided Self, and the Process of its Unification, Conversion, Saintliness, and Mysticism. James makes the point that an objects (religions) origin or objective judgment of its basis does not necessarily affect its value. Parts of this were relevant to my research on depersonalization, mostly in the section on mysticism. Some of the spiritual experiences recorded here bear resemblance to depersonalization in the sense of their life seeming like a dream, or the immediate terror/panic that can accompany depersonalization, or a seeming split between the

observing/experiencing self. Connecting actual spiritual experiences with symptoms of depersonalization, as opposed to just tenets, is especially useful and strengthens the connection between the two.

Laura, R. S., Marchant, T., & Smith, S. R. (2008). The new social disease: From high tech depersonalization to the survival of the soul. Lanham, MD: University Press of America.

This book explores the role of technology and the internet in the perceived dehumanization happening in our culture. It explores the ways we use technology and how that does and does not benefit us as consumers. Technology here extends beyond electronics to many man-made/processed commodities. The authors present evidence of ways in which these different technologies impact both our physical and social health. Though part of the authors meaning in depersonalization refers to social identity, large parts of this book are applicable to my research. Inauthenticity has become so commonplace in wielding technology the way modern society does; its just one step farther to the chronic disconnect and estrangement that is depersonalization disorder. Seeing specific research on social effects of the internet, though not always approached even-handedly in this book, was also quite relevant.

Medford, N., Baker, D., Hunter, E., Sierra, M., Lawrence, E., Phillips, M. L., & David,

A. S. (2003). RESEARCH REPORT Chronic depersonalization following illicit drug use: a controlled analysis of 40 cases. Addiction, 98(12), 1731-1736. doi:10.1111/j.1360-0443.2003.00548.x

This study examines the link between onset of chronic depersonalization and drug use. 164 participants went through standardized questionnaires and clinical assessments. The researchers found that the drug-induced depersonalization group was younger and had more males than the non-drug induced group. Additionally, the authors concluded that drug-induced depersonalization does not represent a syndrome distinct from depersonalization. I found this study moderately relevant to my research. Its worth knowing specifically that different precipitants of depersonalization have been studied for their potential as individual disorders. But like other articles on depersonalization, it is very narrow in scope and basically only presents one fact or so on depersonalization.

Neziroglu, F., & Donnelly, K. (2010). Overcoming depersonalization disorder: A mindfulness & acceptance guide to conquering feelings of numbness & unreality. Oakland, CA: New Harbinger Publications.

This book is a fresh perspective on working with DPD. Though it does have a basic informational section on the neurobiology and psychology of DPD, with some case studies, it differs from other texts by spending most of its time applying that information to a few different forms of psychotherapy. Of these, the most time is spent on ACT, or

Acceptance & Commitment Therapy. This therapy is used mainly to work through avoidance of personal triggers of depersonalization symptoms. A second and lessdiscussed therapy is dialectical behavior therapy, or DBT. I used this book for multiple parts of my research on DP. Its main focus is therapeutic treatment, and the inclusion of ACT is very unique and worth mentioning. Secondary to that are smaller, but still useful, sections on neurobiology, a discussion of DPs causes, and physical/psychopharmacological forms of treatment. Of those, the interpretation/explanation of DPs neurobiology is especially useful to me.

Phillips, M., Hunter, E., Baker, D., Medford, N., Sierra-Siegert, M., & David, A. (2005). DEPERSONALIZATION DISORDER. Current Medical Literature: Psychiatry, 16(1), 1-4. Retrieved from EBSCOhost.

The content of this article is just a short overview of DPD. Areas discussed include depersonalizations clinical features, its neurobiology and psychology, and pharmacological and psychotherapeutic treatment. The authors conclude by saying their (and others) research is aiding the increase in awareness of depersonalization. As an overview of depersonalization, this article is of course relevant to my work. Compared to other sources, there isnt much to make it stand out, though. The information it containted was generally a summarization of/reference to other sources with which I am familiar. Still, I think it is useful to see how the authors summarized what they knew, and I will apply that in my paper.

Sartre, J.-P. (2007). Nausea. New Directions Publishing.

Sacco, R. G. (2010). The Circumplex Structure of Depersonalization/Derealization. International Journal of Psychological Studies, 2(2), 26-40. Retrieved from EBSCOhost.

The authors of this article hold up the various precipitating states and couses of depersonalization to the circumplex model of emotion. They do this in order to see how well those states and causes actually map onto the circumplex model. The states and causes discussed range from hypnosis and sleep deprivation to sports and overwhelming joy. The models applicability established, the authors discuss its implications, and conclude that DP/DR is associated with a wide range of altered state of consciousness. This article managed to be relevant and interesting. Rather than being another small puzzle-piece study, this article incorporates many different aspects of what is known of depersonalization as a symptom and a disorder. It discusses these aspects in the very unique, unexplored frame of the circumplex model of emotions. I can use this discussion to help me present what is known about depersonalization in a different context than just clinical presentation.

Sierra, M. (2010). Depersonalization: A new look at a neglected syndrome. Cambridge, UK: Cambridge University Press.

This book basically collected and summarized all the known research and studies and clinical writings/observations about depersonalization. The author sticks entirely to the research, and the summarization/analysis thereof. The main topics covered are depersonalizations history, symptoms, neurobiology, spectrum of experience, psychiatric comorbidity, pharmacological + psychological treatments/therapies, and depersonalization in the context of different cultures. This text was a very good resource on depersonalization for me. Though the clinical and sometimes (to my eye) unexplained/conclusion-less information wasnt what I was looking for, there were a few interesting things unique to this book. Its analysis of depersonalizations prevalence by culture, discussion of consistency in efficacy in psychopharmacology, and description of psychiatric comorbid disorders were informative sections entirely unique to this book.

Simeon, D. (2004). Depersonalisation Disorder: A Contemporary Overview. CNS Drugs, 18(6), 343-354. Retrieved from EBSCOhost.

This article is a brief summary of what research there is on DPD, though it is longer than other articles like it. Topics covered include defining depersonalization, its prevalence, clinical presentation, psychiatric comorbidity, relation to trauma, neurobiology, and different forms of treatment/therapy. Just presenting these, the authors draw no conclusions of their own.

The content of this article is relevant if not unique. I can use the summarized, more accessible version of the discussion of neurobiology and pharmacological treatment, certainly, Otherwise, there is nothing particularly original to this article.

Simeon, D., & Abugel, J. (2006). Feeling unreal: Depersonalization disorder and the loss of the self. New York, NY: Oxford University Press.

This text on depersonalization has both a clinical and an exploratory side. Of course, included in this comprehensive book are sections on depersonalizations history, symptoms, neurobiology, forms of treatment, et cetera, but also on the philosophy of depersonalization: its exploration in more soulful settings, in fiction and otherwise. The authors succeeded in compiling and discussing a breadth of information on depersonalization in a fair and accessible manner. I found every aspect of Feeling Unreal useful. The inclusion of previous and current perspectives in medicine and other literature gave me many angles of insight, not just what is known. The standard inclusion of neurobiology/neurochemistry and treatment is very relevant, if not unique to this book. The most unique and useful piece offered by this book was its balanced way of discussing information in-depth without pushing any conclusions on the reader.

Steinberg, M., & Schnall, M. (2001). The stranger in the mirror: Dissociation the hidden epidemic. New York, NY: HarperCollins.

Steinbergs book on dissociation is written with a wide audience in mind. Published in 2001, it is perhaps not the most up-to-date text on the subject, but remains an excellent, thorough introduction to dissociative disorders. Its symptoms are explored in depth, with a questionnaire for each. Steinberg then presents three case studies of Dissociative Identity Disorder, and finishes with a discussion of treatment and potential explanation of certain metaphysical phenomena as a dissociative reaction to trauma. This was indirectly useful to me. Though depersonalization was not the disorder of focus in this book, the causes, symptoms, and diagnoses of dissociation in general are still applicable enough to my learning and Steinberg took a very uniquely human angle on the subject that made it all the more useful. In addition, traumas relation to dissociation was a topic I hadnt had the chance to explore so thoroughly prior to reading this.

Fluoxetine not efficacious for depersonalization disorder. (2004). Brown University Psychopharmacology Update, 15(9), 3-4. Retrieved from EBSCOhost.

This article summarizes the results of a study done on the effects of fluoxetine, an SSRI, on depersonalization. The researchers set up a randomized, double-blind, placebocontrolled trial. They found that outside of a subgroup of participants who either had a depressive or anxiety disorder, fluoxetine had no more effect than the placebo, aside from the side effects and withdrawal. It was suggested that any positive effects were related to

increased tolerance of depersonalization symptoms, not a change in the symptoms themselves. The study discussed here is relevant to my research on depersonalization in a few ways. First, it shows different effects of an SSRI upon those in the study diagnosed with depressive/anxiety spectrum disorders and those with just depersonalization, supporting the claim that depersonalization is a dissociative disorder instead. Second, and more interesting, it mentions a difference between symptom relief and emotional perspective on those symptoms- serotonergic systems may be peripherally involved here, but perhaps not with depersonalization, itself.