Psychosocial impact of depersonalization: Depression, anxiety, and suicidality

by Zinnia Jones — October 31, 2017

Depersonalization is a cluster of mental health symptoms encompassing feelings of “unreality”, including emotional numbness, feeling that the world is flat or lifeless, or sensing that one’s conscious experience is lacking in some essential quality. While depersonalization (and the clinical syndrome, depersonalization disorder) is an underrecognized condition among the general public as well as clinicians, these symptoms are highly distressing and are frequently associated with severe psychiatric comorbidities and functional impairments in many areas of life. The DSM-5 describes the impact of depersonalization/derealization disorder as follows (American Psychiatric Association, 2013, pp. 304–305):

Symptoms of depersonalization/derealization disorder are highly distressing and are associated with major morbidity. The affectively flattened and robotic demeanor that these individuals often demonstrate may appear incongruent with the extreme emotional pain reported by those with the disorder. Impairment is often experienced in both interpersonal and occupational spheres, largely due to the hypoemotionality with others, subjective difficulty in focusing and retaining information, and a general sense of disconnectedness from life.

Extensive studies across several decades have established the wide variety of conditions and symptoms associated with depersonalization, including depression, anxiety, suicidal ideation, suicidal planning, suicide attempts, impaired general functioning, and impaired social and occupational functioning.

 

Comorbidity, clinical course, and causation

Simeon et al. (1997) note that intense distress and interpersonal impairment, as well as depressive and anxiety disorders and personality disorders, are common and characteristic of depersonalization. However, the authors go on to note that depersonalization did not appear to be predated by these conditions in a clinical sample:

Statistical analyses suggested that no disorders specifically predated depersonalization, correlated with its onset, or determined its severity.

On this basis, Simeon (2004) observes that depersonalization should be considered a distinct condition in its own right, not a symptom that necessarily results from depressive or anxious conditions:

There is frequent comorbidity with Axis I mood and anxiety disorders in depersonalisation disorder, as we have found in our initial series of 30 patients and similarly in our expanded series of 117 patients to date. However, none of these disorders have been found to have an onset prior to depersonalisation disorder, and none predict the severity of symptoms. Similarly, there is extensive comorbidity with Axis Il personality disorders, found in about 60% of patients. The most common are borderline, avoidant and obsessive-compulsive disorder; however, all personality disorders are represented. As with Axis I, no Axis Il disorder emerges as uniquely related to the presence or severity of depersonalisation disorder. Thus, these findings support the conceptualisation of depersonalisation disorder as a distinct disorder with its own standing, rather than a depressive or anxious equivalent as some clinicians are still prone to thinking.

 

Depression

• Simeon et al. (1997) found that of 30 patients with clinical depersonalization, 53% had a diagnosis of major depression at some point in their lifetime, while 33% had a lifetime diagnosis of dysthymia (persistent depressive disorder).
• In a followup study of 117 patients with depersonalization disorder, including the 30 previous subjects, Simeon, Knutelska, Nelson, & Guralnik (2003a) observed that 66.7% had a lifetime diagnosis of major depression, and 30.8% had a lifetime diagnosis of dysthymia. In all, 73% had a unipolar mood disorder over their lifetime.
• Baker et al. (2003) found that of 204 patients with depersonalization, 62% had also received a diagnosis of depression. Additionally, 42% had been hospitalized for psychiatric reasons at least once, and of that group, 35% had been admitted for major depression.
• Michal et al. (2011a) found that in a sample of 2,512 participants from the general population, 90.1% of those with clinical levels of depersonalization also experienced clinical levels of depression. Increased severity of depersonalization was also associated with a higher likelihood of clinical depression.
• In a community sample of 5,000 participants, Michal et al. (2011b) observed that 70.7% of individuals with clinical depersonalization had depression as well, compared to only 5.2% of those who did not have depersonalization.
• Michal et al. (2016) found that out of 223 patients with depersonalization disorder, 84.8% had a depressive disorder.

 

Anxiety and distress

• Simeon et al. (2003a), in a study of 117 patients with depersonalization disorder, found that 64% had been diagnosed with an anxiety disorder during their lifetime.
• Simeon, Riggio-Rosen, Guralnik, Knutelska, & Nelson (2003b) found that patients with depersonalization disorder scored significantly higher on a measure of anxiety compared to healthy controls.
• Baker et al. (2003) observed that among 204 subjects with depersonalization, 41% had been diagnosed with an anxiety disorder.
• In a sample of 2,512 members of the general population, Michal et al. (2011a) found that among those with clinical levels of depersonalization, 76.8% also exhibited clinical levels of anxiety symptoms.
• Michal et al. (2011b) observed that in a sample of 5,000 participants from the general population, 63.4% of those with clinically significant depersonalization symptoms also had significant anxiety symptoms, compared to only 5.6% of those without depersonalization.
• In a study of 3,809 students from the general population aged 12–18, Michal et al. (2015) found that of those with depersonalization, 82% scored highly on the Global Severity Index of the SCL-90, an overall measure of psychological distress. Only 25.5% of students without depersonalization scored highly on this measure.
• Michal et al. (2016) observed that in a group of 223 patients with depersonalization, 42.6% had an anxiety disorder, compared to only 30.5% of a control group of patients with depression.

 

Suicidality

Suicidal ideation

• In a community sample of 5,000 people, Michal et al. (2010) found that individuals with clinical levels of depersonalization were 2.45 times as likely as those without depersonalization to experience suicidal ideation.
• Tosić-Golubović, Žikić, Slavković, Nikolić, & Simonović (2017) found that among a sample of 119 depressed patients, those with depersonalization (n = 50) were significantly more likely to suffer from suicidal ideation than those without depersonalization.

Suicidal desire

• Tosić-Golubović, Žikić, Slavković, Nikolić, & Simonović (2017) observed that 82% of depressed patients with depersonalization had active suicidal desire, compared to only 36.2% of patients without depersonalization. 80% of those with depersonalization also had passive suicidal desire, versus only 26.1% of those without depersonalization.

Suicidal planning

• Tosić-Golubović, Žikić, Slavković, Nikolić, & Simonović (2017) found that 56% of depressed patients with depersonalization had engaged in planning suicide, compared to 20.3% of depressed patients without depersonalization.

Suicide attempts

• Tosić-Golubović, Žikić, Slavković, Nikolić, & Simonović (2017) found that 50% of depressed patients with depersonalization had at least one previous suicide attempt, versus only 18.8% of depressed patients without depersonalization.

 

Next: Depersonalization’s impact on employment, relationships, academic performance, and overall social and occupational functioning.

< Back to: Depersonalization

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References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. [Excerpt]
• Baker, D., Hunter, E., Lawrence, E., Medford, N., Patel, M., Senior, C., . . . David, A. S. (2003). Depersonalisation disorder: clinical features of 204 cases. British Journal of Psychiatry, 182(5), 428–433. [Full text]
• Michal, M., Adler, J., Wiltink, J. Reiner, I., Tschan, R., Wölfling, K., . . . Zwerenz, R. (2016). A case series of 223 patients with depersonalization-derealization syndrome. BMC Psychiatry, 16, 203. [Full text]
• Michal, M., Duven, E., Giralt, S., Dreier, M., Müller, K. W., Adler, J., . . . Wölfling, K. (2015). Prevalence and correlates of depersonalization in students aged 12–18 years in Germany. Social Psychiatry and Psychiatric Epidemiology, 50(6), 995–1003. [Abstract]
• Michal, M., Glaesmer, H., Zwerenz, R., Knebel, A., Wiltink, J., Brähler, E., & Beutel, M. E. (2011a). Base rates for depersonalization according to the 2-item version of the Cambridge Depersonalization Scale (CDS-2) and its associations with depression/anxiety in the general population. Journal of Affective Disorders, 128(1–2), 106–111. [Abstract]
• Michal, M., Wiltink, J., Till, Y., Wild, P. S., Blettner, M., & Beutel, M. E. (2011b). Distinctiveness and overlap of depersonalization with anxiety and depression in a community sample: results from the Gutenberg Heart Study. Psychiatry Research, 188(2), 264–268. [Abstract]
• Michal, M., Wiltink, J., Till, Y., Wild, P. S., Münzel, T., Blankenberg, S., & Beutel, M. E. (2010). Type-D personality and depersonalization are associated with suicidal ideation in the German general population aged 35-74: results from the Gutenberg Heart Study. Journal of Affective Disorders, 125(1–3), 227–233. [Abstract]
• Simeon, D. (2004). Depersonalisation disorder: a contemporary overview. CNS Drugs, 18(6), 343–354. [Abstract] [Full text]
• Simeon, D., Gross, S., Guralnik, O., Stein, D. J., Schmeidler, J., & Hollander, E. (1997). Feeling unreal: 30 cases of DSM-III-R depersonalization disorder. American Journal of Psychiatry, 154(8), 1107–1113. [Abstract] [Full text]
• Simeon, D., Knutelska, M., Nelson, D., & Guralnik, O. (2003a). Feeling unreal: a depersonalization disorder update of 117 cases. Journal of Clinical Psychiatry, 64(9), 990–997. [Abstract]
• Simeon, D., Riggio-Rosen, A., Guralnik, O., Knutelska, M., & Nelson, D. (2003b). Depersonalization disorder: dissociation and affect. Journal of Trauma & Dissociation, 4(4), 63–76. [Abstract]
• Tosić-Golubović, S., Žikić, O., Slavković, V., Nikolić, G., & Simonović, M. (2017). Relationship of depersonalization and suicidality in depressed patients. Vojnosanitetski Pregled. Advance online publication. doi:10.2298/VSP161201023T [Full text]