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Depersonalization: A New Look at a Neglected Syndrome

Alan D. Schmetzer, MD

Indiana University School of Medicine, Indianapolis, IN, USA

By Mauricio Sierra, MD, PhD. New York, NY: Cambridge University Press; 2009; ISBN: 978-0-52187-498-4; pp 182; $90.00 (hardcover).

In 11 chapters, this book explores most of the issues surrounding the dissociative phenomenon termed depersonalization disorder in DSMIV-TR. Dr. Sierra has devoted consistent interest and effort to this condition for much of his career, writing or coauthoring a number of articles and book chapters on the subject. He currently holds an appointment to the faculty of the Depersonalization Research Unit of the Institute of Psychiatry at the Maudsley, Kings College London. The primary purposes of this book seem to be to make the case for depersonalization as a separate, fairly common diagnosis—not simply a symptom of other disorders or some psychological rarity—and to illuminate at least a few of the shadows that continue to surround it.

The book begins with a chapter devoted to the history and conceptualization of, depersonalization disorder, including quotations from descriptions and reports of case series from the 1830s and 1840s. Sierra reports that the first truly systematic account of the disorder came from Hungarian ear, nose, and throat specialist Maurice Krishaber, who published a case series of 38 patients in 1873 in France under the term névropathie cérébro-cardiaque. The term depersonalization was evidently introduced into the literature in 1894 by Ludovic Dugas, who was studying the phenomenon of déjà vu at the time. Dugas said that he borrowed the term from a phrase found in the personal diary (Journal Intime) of Swiss philosopher Henri-Frédéric Amiel. The term derealization was added to the official mix of terminology in 1935 by Wilhelm Mayer-Gross.

Early concepts regarding the disorder were heavily influenced by the prevailing philosophical and psychological ideas of their day, and read like a Who’s Who of late 19th and early 20th century philosophers and neuropsychiatrists. These theories regarding the causation or underlying core of the condition include sensory distortion (from Krishaber himself and Théodule-Armand Ribot), a dysfunction of one of the “mental faculties” (based on the philosophy of Immanuel Kant), memory impairment (Emil Kraepelin), disturbances of feelings or affect (G. Storring et al), body image distortion (Henri Ey), a problem of “self-belonging” (Karl Jaspers), improper “self experience” (Pierre Janet), and various conceptualizations by psychoanalysts such as Paul Federn, Clarence P. Oberndorf, and Otto Fenichel regarding libidinal investment, “counter cathexis against one’s own feelings,” or a mechanism similar to that of schizophrenia. More modern work has placed the disorder into the spectra of anxiety-related or dissociative disorders.

The subsequent chapters explore symptom phenomenology, the depersonalization spectrum, examples of drug-induced depersonalization, other psychiatric conditions that are frequently comorbid with depersonalization, neurologic correlates (such as epilepsy, migraine, head trauma, etc), a cross-cultural perspective (including discussions of studies on the disorder’s prevalence in various parts of the world, which have produced highly variable results of 7% to 80%), pharmacologic and psychological approaches to treatment, and the neurobiology of depersonalization (that is, which circuits and brain structures appear to be involved).

The final chapter, “Pulling the threads together,” restates some of the earlier chapters’ most important conclusions, along with a couple of cases and some examples of treatment effects; however, should you be looking for this, it does not summarize all of the foregoing information into some sort of neat gestalt. The 29-item Cambridge Depersonalization Scale, developed by the author along with German E. Berrios, is included as the book’s only appendix, followed by the subject index.

Overall, this is a very readable and comprehensive discussion of depersonalization. It covers a vast amount of clinical and theoretical territory in a well-organized and informative manner. Psychiatrists and psychiatric residents, clinical psychologists and clinical psychology interns, psychiatric social workers, and other therapists of all types will find this volume, or at least various chapters within it, useful in understanding and treating some of their patients’ or clients’ more vexing and confusing psychological complaints of personal but nonpsychotic “unreality” or “disconnectedness.”

Depersonalization, like so many other difficulties that can be seen as parts of highly different diagnoses or as independent, standalone disorders—catatonia comes to mind—has been neither well understood nor easily diagnosed and treated, despite nearly 2 centuries of clinical description and research. Dr. Sierra has gone a long way toward improving our understanding and clinical capability with this succinct and carefully written exposition of the range of symptoms, potential core neuropathology, and possible treatment approaches for this formerly “neglected” condition.