Orna Guralnik

The detection and measurement of depersonalization disorder

Depersonalization disorder comprises one of the four major dissociative disorders and yet remains poorly studied. There are no reports describing the application of dissociation scales to this population. Our goal was to investigate the applicability of four such scales to depersonalization disorder and to establish screening criteria for the disorder. Two general dissociation scales and two depersonalization scales were administered to 50 subjects with DSM-III-R depersonalization disorder and 20 healthy control subjects. The depersonalization disorder group scored significantly higher than the normal control group in all scales and subscales. Factor analysis of the Dissociative Experiences Scale (DES) yielded three factors as proposed previously, absorption, amnesia, and depersonalization/derealization. A DES cutoff score of 12, markedly lower than those previously proposed for the screening of other dissociative disorders, is required for the sensitive detection of depersonalization disorder. Alternatively, the DES pathological dissociation taxon (DES-taxon) score recently generated in the literature appears more sensitive to the detection of depersonalization disorder and is better recommended for screening purposes. The other three scales were fairly strongly correlated to the DES, suggesting that they may measure similar but not identical concepts, and cutoff scores are proposed for these scales also. General implications for the screening and quantification of depersonalization pathology are discussed.

Basal norepinephrine in depersonalization disorder.

In contrast to the noradrenergic dysregulation described in PTSD, little is known regarding noradrenergic function in dissociative disorders. The purpose of this preliminary study was to investigate basal norepinephrine in depersonalization disorder (DPD). Nine subjects with DSM-IV DPD, without lifetime PTSD, were compared to nine healthy comparison (HC) subjects. Norepinephrine was measured via 24-h urine collection and three serial plasma determinations. Groups did not differ significantly in plasma norepinephrine levels. Compared to the HC group, the DPD group demonstrated significantly higher urinary norepinephrine, only prior to covarying for anxiety. The DPD group also demonstrated a highly significant inverse correlation between urinary norepinephrine and depersonalization severity (r=-0.88). Norepinephrine and cortisol levels (reported in a prior study) were not intercorrelated. We concluded that although dissociation accompanied by anxiety was associated with heightened noradrenergic tone, there was a marked basal norepinephrine decline with increasing severity of dissociation. The findings are in concordance with the few reports on autonomic blunting in dissociation and merit further investigation.

Cognitive Functioning in Depersonalization Disorder

Depersonalization disorder (DPD) is a dissociative disorder characterized by a subjective sense of unreality and detachment, and has been associated with deficits in perception and short-term memory. In this study, 21 DPD and 17 healthy comparison participants free of psychiatric disorders were administered a comprehensive neuropsychologic battery. The groups did not differ in full-scale, verbal, and performance IQ (Wechsler Adult Intelligence Scale), in working memory (Paced Auditory Serial Addition Test), or in selective attention (Digit Span with Distracters). The DPD group performed significantly worse on immediate visual and verbal recall (Wechsler Memory Scale, Revised), but not on delayed recall. Dissociation severity was significantly correlated with processing slowness and distractibility. We conclude that DPD is associated with cognitive disruptions in early perceptual and attentional processes.

Examination of the pathological dissociation taxon in depersonalization disorder.

In recent years, the pathologic dissociation taxon developed by Waller, Putnam, and Carlson (Psychological Methods 1:300–321, 1996) from a Dissociative Identity Disorder (DID) sample has been increasingly used in studies of dissociation in general. However, the taxon’s convergence with dissociative diagnoses other than DID, as well as the taxon’s central premise that pathologic dissociation is a categorical rather than a dimensional construct, remain areas of exploration. This report examines the applicability of the pathologic dissociation taxon to Depersonalization Disorder (DPD). The Dissociative Experiences Scale was administered to 100 consecutively recruited DPD subjects diagnosed by semistructured clinical interview and by the SCID-D. Taxon membership probability was calculated using the recommended SAS scoring program. Approximately 2/3 of subjects (N = 64) had a very high probability (> .80) of belonging to the taxon, while 1/3 of subjects had a very low probability (<.10) of belonging to the taxon. A taxon cutoff score of 13 yielded an 81% sensitivity in detecting the presence of DPD. The modest convergence between taxonic membership and clinical dissociative disorder diagnosis suggests that the taxon may have important limitations in its use, at least when applied to DPD in its current form. As previously, we continue to recommend a low taxon cutoff score (13) for the sensitive detection of depersonalization disorder. The inference that pathologic dissociation is a unitary and categorical entity is also discussed.

Hypothalamic-pituitary-adrenal Axis Dysregulation in Depersonalization Disorder

Background: The purpose of this preliminary study was to investigate HPA axis function in dissociation. Methods: Nine subjects with DSM-IV depersonalization disorder (DPD), without lifetime Posttraumatic Stress Disorder (PTSD) or current major depression, were compared to nine healthy comparison (HC) subjects of comparable age and gender. Results: DPD subjects demonstrated significant hyposuppression to low-dose dexamethasone administration and significantly elevated morning plasma cortisol levels when covaried for depression scores, but no difference in 24-hour urinary cortisol excretion. Dissociation scores powerfully predicted suppression whereas depression scores did not contribute to the prediction. Conclusions: Primary dissociative conditions, such as depersonalization disorder, may be associated with a pattern of HPA axis dysregulation that differs from PTSD and merits further study.

Development of a depersonalization severity scale

Our aim was to develop a clinician-rated scale assessing depersonalization severity for use in clinical trials of Depersonalization Disorder and trauma-related disorders in general. The 6-item Depersonalization Severity Scale (DSS) was administered to 63 participants with DSM-IV Depersonalization Disorder as diagnosed by the SCID-D, and its psychometric properties were examined. The sensitivity of the DSS and of the Dissociative Experiences Scale (DES) to treatment change was assessed in blinded, controlled settings. Individual items were widely distributed across the severity range. Interrater reliability was excellent and internal consistency was moderate. The DSS had high convergent and discriminant validity and was sensitive to treatment change. The DES was also sensitive to treatment change. We recommend piloting the DSS in future treatment trials of trauma-spectrum disorders.

Depersonalization Disorder: Dissociation and Affect

ABSTRACT Dissociation and affect are intimately related constructs, but their relationship has not been subjected to extensive empirical study. This report investigates the relationship between dissociation and affect in depersonalization disorder. Fifty-six participants with DSM-IV depersonalization disorder (DPD) and 22 healthy comparison participants (HC) were administered the Dissociative Experiences Scale, the Multidimensional Anger Inventory, and the Spielberger Trait Anxiety Inventory. A subgroup of participants also completed the Affect Intensity Measure and the Boundary Questionnaire. Individuals with depersonalization disorder experienced more anxiety, anger, negative affect intensity, and thinner boundaries than healthy individuals, but did not differ in positive affect intensity. Within the DPD group, severity of pathological dissociation and of depersonalization were more strongly related to greater anxiety than to greater anger. The DPD group had higher negative than positive affect intensity, whereas in the comparison group opposite valences were of comparable intensity. In the combined sample, anxiety was the strongest predictor of depersonalization and pathological dissociation, anxiety followed by anger predicted absorption, while anger predicted amnesia. Our overall findings suggest that, at least in depersonalization disorder, pathological dissociation is more intimately related to anxiety than to anger. The findings also suggest that chronic depersonalization is a poor regulator of affect, since it is associated with persistent chronic elevations in frequency and intensity of negative affect. More elaborate research into the relationships between affect and dissociation would be fruitful.

Dissection of schizotypy and dissociation in Depersonalization disorder

ABSTRACT The relationship between dissociation and psychosis-proneness remains controversial to this day. We investigated this relationship in Depersonalization Disorder, a primary dissociative disorder, hypothesizing that the constructs of schizotypy and dissociation would be distinguishable. Forty-eight depersonalization disorder (DPD) and 22 healthy comparison (HC) participants were administered measures of schizotypy (Perceptual Aberration Scale, Magical Ideation Scale) and dissociation (Dissociative Experiences Scale). The DPD group had significantly higher schizotypy scores than the HC group. However, when DPD participants with Axis II disorders were excluded, the remaining “pure” DPD group (N = 22) exhibited higher perceptual aberrations but comparable magical ideations to the healthy group. Within the “pure” DPD group, dissociation and schizotypy scores were not significantly correlated. We conclude that schizotypy was readily distinguishable from dissociation in the current sample. Greater attention to methodological issues promoting the distinction between dissociation and schizotypy may prove helpful in future phenomenological research.

Dreams of personality disordered subjects

Dreams provide access to underlying personality structure, defensive and adaptive functions, and they elucidate the psychological forces that lead to overt symptomatic behavior. Two hundred three dreams of 39 personality disordered patients were factor analyzed and compared with Hall and Van de Castles normative data (Hall C, Van de Castle RI [1966] The content analysis of dreams. New York: Appleton-Century-Crofts). Results included a five-factor solution that sheds light on some core issues of the dreamers. Comparisons between the groups resulted in the personality-disordered group demonstrating more estrangement in their dreams, fewer interactions, and more emotionality. In their interactions, they demonstrated a lower ratio of aggressive interactions yet a higher tendency to view themselves as the aggressor. Results are related to theoretical literature on personality and defensive styles, mostly from a psychodynamic perspective.