Psychosocial impact of depersonalization: Social and occupational impairment

by Zinnia Jones — October 31, 2017

 

General functional impairment

The DSM-5 description of depersonalization/derealization disorder notes that these symptoms can be severely impairing to an individual’s life (American Psychiatric Association, 2013, pp. 304–305):

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.

Simeon et al. (1997) vividly described the effects of this disinvestment from life on sufferers’ work and relationships:

Many of the fully employed subjects reported that depersonalization substantially interfered with their capacity to work at a level concordant with their education and abilities.

All subjects described suffering from distress or functional impairment that was associated with their depersonalization. Distress ranged from relatively mild (“I am so used to it, I cannot remember what it feels like not to have it”) to profound (“Life has no meaning like this . . . I would rather be dead than continue living like this. It is like the living dead”). Impairment also ranged from relatively mild to extreme. Subjects who held jobs or were in significant relationships frequently described being unable to derive satisfaction or pleasure from these facets of their lives because they felt detached and disconnected from their activities or from other people, even in intimate settings. Almost uniformly, subjects felt that the depersonalization interfered more with interpersonal relatedness than their being able to work.

Simeon (2004) further noted that the cognitive and emotional effects of depersonalization can have a severe impact on daily life:

The distress associated with depersonalisation disorder can be profound. Many people experiencing it find the robotic, detached state analogous to the ‘walking dead’, and deeply question the meaning of being alive if they do not feel alive and real. Fears of going crazy, losing control and having permanent brain damage are also common. Cognitive complaints are frequent, specifically a decline in ability to focus on tasks, especially complex ones increased forgetfulness in their daily lives and difficulty in vividly evoking past memories. Accordingly, specific attention and memory deficits have been demonstrated with neuropsychiatric testing. As a result of these deficits, complaints of occupational impairment are very common and many individuals feel they are working at well below their previous capacity, some are even unable to work. Interpersonally as well, people experiencing depersonalisation disorder are often troubled by the intense sense of emotional disconnection from those they care about.

Baker et al. (2003) found that 79% of a group of patients with depersonalization “reported impaired social and/or work functioning”. Michal et al. (2016) further observed that sufferers of depersonalization disorder had greater functional impairment than a control group of depressed patients, and those with depersonalization reported more disruption in their work and social life due to these symptoms. The global level of functioning of depersonalization patients was also found significantly lower than that of depressed patients, and the authors noted that “35.2 % had a GAF below 50 which, in Germany, is considered as a criterion for inpatient psychotherapy”.

 

Employment

Simeon, Knutelska, Nelson, & Guralnik (2003) described the difficulties that sufferers of depersonalization can experience with working at their level of ability:

Numerous employed individuals described that their depersonalization strongly prevented them from employment that was correspondent to their level of training or intellectual capacities. Specifically, cognitive interference in their occupation having to do especially with difficulty focusing and cognitive deterioration with overstimulation were frequently described.

Michal et al. (2016) found that in a group of patients with clinical depersonalization, only 33.2% were employed full-time or part-time, compared to 46.4% of a control group of depressed patients without depersonalization.

 

Relationships

In a study of 117 patients with depersonalization, Simeon et al. (2003) found that 68% were single, while 6% were separated, 10% were divorced, and 16% were married. The authors note:

The very low proportion of individuals involved in committed long-term relationships was reflective of the common subjective report of deficits in the sense of interpersonal connectedness.

Michal et al. (2016) observed that among a group of patients with depersonalization disorder, only 44.4% were currently in a relationship, compared to 59.1% of a control group of patients with depression.

 

Independent living

Michal et al. (2016) found that 25.9% of a group of depersonalization patients were currently living in their parents’ household, compared to only 9.6% of patients with depression.

 

Avoidant personality disorder

Avoidant personality is described as a “pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation” (American Psychiatric Association, 2013, p. 672). In a study of 30 patients with depersonalization disorder, Simeon et al. (1997) found that avoidant personality disorder was the most commonly reported personality disorder, with 30% experiencing this disorder. In a followup of 117 patients with depersonalization disorder, including the original 30 participants, Simeon et al. (2003a) found that 23% suffered from avoidant personality disorder. However, Sierra (2009) questions whether the prevalence of avoidant personality among those with depersonalization is due to overlap with social anxiety:

This personality disorder is characterized by pervasive social inhibition and avoidance of social interaction. Patients have deeply rooted feelings of inadequacy, and extreme sensitivity to negative evaluation by others. It is a category which clearly overlaps with social phobia and can be viewed as a particularly severe, persistent and generalized form of social anxiety. In fact, 50%–90% of patients with social phobia are also diagnosed with avoidant personality disorder. Such overlap between the two conditions has cast doubt on the validity of ‘avoidant personality disorder’ as an independent condition. In this regard, a high prevalence of ‘avoidant personality disorder’ amongst patients with depersonalization disorder is hardly surprising.

 

Maladaptive coping strategies

In a study of 3,809 students aged 12–18 in the general population, Michal et al. (2015) found that pupils with clinical levels of depersonalization were more likely to exhibit “increased avoidant and less problem-oriented coping strategies” than those without depersonalization. Differences were found in social insecurity as well as coping strategies of “self-distraction, behavioral disengagement and self-blame”.

 

Academic struggles

Michal et al. (2015) also observed that students with depersonalization were less likely than those without depersonalization to attend high school (15.3% vs. 28.2%), more likely to have to repeat a year of school (32.6% vs. 21.4%), and more likely to have to move to another school (50.8% vs. 39.8%).

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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]
• 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. (2003). Feeling unreal: a depersonalization disorder update of 117 cases. Journal of Clinical Psychiatry, 64(9), 990–997. [Abstract]