D E P E R S O N A L I Z A T I O N SYNDROME:

AN O V E R V I E W

Evan M. Torch, M . D .

Depersonalization syndrome is an intriguing condition which entails the inclusion of both

philosophical and psychiatric considerations. The author presents a clinical review of the
syndrome with the inclusion of four essential components classically included in the
literature. These components include a possible preformed response of the brain, an
obsessional quality, a depressive element and a tendency towards a peculiar perseveration.

There are few disorders in the realm of psychiatric research which have
attracted the attention displayed towards depersonalization as a symptom, a
syndrome or metaphysical phenomenon. T h r o u g h every era, including our
own"biologically centered" age, prominent authors seem to have been highly
interested in examining this complex state from several vantage points, and
writing about the subject in early psychoanalytic studies took on a rich and
multivaried air.
M a n y reasons for this interest would seem to offer themselves up for
analysis, but the chief explanation can perhaps be found in the difficulty which
the occurrence, undeniable as it is in the psychic content of patient and therapies
alike, presents in definition. The therapist must identify as a disorder a group of
facts which the patient relates in an "as if" manner, with both detached and
paradoxically intense affects, an obsessional persistance, and in such terms as to
suggest a close relation to what often seems to be more philosophical perspective
than psychiatric enigma. Indeed, "noticing o n e ' s own actions and thoughts" is
one prerequisite for h u m a n intelligence, so it would seem perhaps predictable
that either everybody should be occasionally depersonalized or odd that anyone
ever would. This is not to deny the certain existence of varied mechanisms of
dissociation; but the question must at least be broached as to why the symptoms
cause the patient such consternation and suffering.
O n e of the greatest difficulties presented by the subject of depersonalization
is found in the attempt to unravel depersonalization as a specific, d o m i n a n t
aspect of a syndrome. This problem seems to be especially prominent in
American diagnostic itemization, as was seen in the preliminary draft of D S M -
I I I 1, where the differentiation was made on the frequency of occurrences in a
specified period of time. This m a y be partly due to Dixon's 2 welt publicized study
where a high proportion o f " n o r m a l " college students experienced the symptom,
or the fact that most textbooks seem to preface discussions of depersonalization
with reminders about its reported concomitant appearance in so m a n y other

Dr. Torch is Unit Director, Georgia Mental Health Institute and Assistant Clinical Professor of
Psychiatry, Emory University School of Psychiatry, Emory University School of Medicine. Reprint
requests should be addressed to Dr. Torch at 2151 Peachford Road, Atlanta, GA 30338.
PSYCHIATRIC QUARTERLY, 53(4) Winter, 1981 249
0033-2720/81/1600-0249500.9501981 Human Sciences Press
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PSYCHIATRIC QUARTERLY

disorders. It is still not entirely clear to the author why there needs to be such an
arbitrary line drawn between the two presentations, since, for example,
depression is treated as a primary factor when it is the primary presenting factor
in a disorder. Yet depression is an accompanying aspect of m a n y other neurotic
and psychotic syndromes. Depersonalization, then, should be treated as a
primary causative factor in a patient's suffering when it is foremost in a clinical
picture, and it is not obviously undergoing rapid alteration or fluctuation with
other primary symptoms. It is important to note, however, that compulsivity
(especially rumination) and hypochondriacal self-scrutiny are often parts of the
syndrome, and may be mistaken for an obsessional or hypochondriacal disorder.
In a previous article on the subject, the author ~ listed four characteristics
which are important in delineating depersonalization syndrome:
1. A feeling of change throughout, of estrangement from the self, and
usually, though not always, a feeling of total change in the subjective perception
of the external world.
2. There is a distinct feeling of unreality present, which shades most of the
patient's clinical picture. Despite the feelings of unreality present, the feelings are
perceived and described in a non-delusional and ego-dsytonic manner, with an
"as if" quality to them.
3. The patient interprets the feelings as being distinctly unpleasant.
4. There is a perplexing and curious subjective report (usually not verified in
objective testing) of a change, usually a diminution, of affect, though the patient
will remain quite able to experience discomfort in his depersonalization.
Patients, especially those less verbal or educated, seem to have a great deal
of difficulty in describing these feelings, very often leading to extreme
exasperation in patient and physician and physician.
Metaphysical associations are usually put forth:

"There is a veil--I can't seem to get hold of the world--it's as ~ I were dead, but
none of it is concrete."
"None of this makes any sense. I laugh but it's like someone else is laughing. It is as
though there is part of me watching and part of me doing it."
" t can't seem to totally wake up. Everything suddenly changed, but I don't know
how. I hate this. There's no use in being alive if my central flame has gone out. It's
almost like I'm dead."

From these patient descriptions, it quickly becomes apparent that the patient
is experiencing quite severe problems in describing a seemingly polar state of af-
fairs, giving rise to intense anguish and an altered state of experiencing internal
and external equilibrium. Yet these are feelings born of seemingly innocuous
observational events, tbr we are all capable of observing our own activities, be
they psychic or "automatic movements", without experiencing this distress.
Roberts 4 provides us with a dynamic reflection of this point in one of his pub-
lished accounts of students experiencing depersonalization (from a paper bearing
the title, interestingly enough, " N o r m a l and Abnormal Depersonalization").

"There is a feeling of e x t r e m e fatigue and an inability to cope with or be interested in

persons or things--coupled with an emotional stress at this inability..."
The most striking feeling being that I did not know what a person was. In other
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E.M. TORCH

words I was saying to myself, " I am a human being and my name is S..., but
whereas this would normally have been a joke or a tautology because I could not
imagine anything else, it here took on significance because of having a feeling of
strangeness--that is, that it could be questioned."

Repeatedly, in both interviews and in a systematic review of the literature, four

factors seem to emerge in the syndrome configuration:

1. A certain " r e a d y and waiting" personality factor substrate--aperf0rmed

"response ' '
2. A n obsessional repetition of an initial experience of unreality.
3. Feelings of hurt, fatigue and disillusionment--aspects of depression.
4. Persistance of a new personality equilibrium, with further obsessional and
depressive features.

A PREFORMED RESPONSE

There seems to be an intrinsic ability on the part of most h u m a n beings to in

some way temporarily alter a conscious state of awareness for varying periods of
t i m e - - a n alteration which runs the gamut from multiple personality to
depersonalization. M a n y authors, a m o n g them J a n e t 5 and Mayer-Gross 6, see
this as a " p r e f o r m e d response" of the brain, usually implying a purposive reac-
tion, such as protection from experiencing a threat to homeostatis of mind or
body.
There is highly intriguing evidence emerging that certain patients with
seizure or lesions of the temporal lobes (especially the left anterior portions),
undergo a peculiar alteration in behavior which seems to leave them not only
more prone to depersonalization (the welt known incidence of alterations of
awareness of self in temporal lobe seizures), but to possess a " t e m p o r a l lobe
personality t y p e " highly resembling descriptions of patients with depersonaliza-
tion as a syndrome.
We will see shortly that obsessional traits, with a particular predilection for
rumination on "emotionally d r y " topics such as time, death, life, and the
meaning of things, are c o m m o n in depersonalization syndrome. Briefly, let us
look at a portion of the Slater and R o t h 1° description of depersonalization
syndrome:

The depersonalization does not appear to be secondary to some other psychiatric

disorder...an abnormal degree of self absorption, withdrawn into fantasy or
rumination about fate, time and death are common features.

Skoog's 1~ classic description also reflects a rather metaphysical, obsessive-

ruminative quality in his patients:

Doubt or uncertainty is the key word even for patients with depersonalization. It is
also the patient with obsessive doubt and related anancasms who most exhibits the
feeling of unreality visa vis the "self"...Such connections were so common in my
material that it appears difficult to distinguish between anancasms and
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PSYCHIATRIC QUARTERLY

depersonalization symptoms manifesting themselves as subjective corpora aliena in

an otherwise adequate experience. "What is a human being? .... Why me?", "Why
do just I live?", "Why is the wall painted green and not some other color?"

When one takes into account such characterizations as these and the high
incidence of depersonalization in the normal populace, it is not surprising that
many" authors postulate an organic basis or substrate for depersonalization.
Reed 12, for example, speaks of a "preparatory set" personality, and Davison's 1~
patients seemed to exhibit specific, though minor, EEG changes, (a factor which
is often reported anecdotally in isolated cases): a slight excess of slower rhythms,
increasing with attacks of depersonalization, together with slowed alpha rhythm
(though this fits well, especially in his material, with depressive pictures).
Now let us examine some of the descriptions of the interictal behavior of
many temoral lobe seizure patients, Waxman and Geschwind 14 claim to have
identified a certain set of behavior patterns which, at least on the surface, bear a
striking similarity to the behavior of many patients with depersonalization
syndrome. Their patients seem to be more prone to religiousity, hypergraphia, a
certain cosmic sense of fate and a preoccupation with detail. Bear 15 in postulating
a syndrome of sensory-limbic hyperconnection, finds that while patients with
right focal lesions seemed to be more "externally emotive (aggressive, depressed,
emotionally labile)," patients with left temporal foci "developed an internal,
ideational-suggestively verbal-pattern of behavior traits (religiousity, philo-
sophical interest, personal destiny, hypergrahia). Even more striking is this
profile of the left temporal epileptic's interictal behavior described by Bear and
Fedio: 16 ,, Left temporal patients were identified with a sense of personal destiny
and a concern for meaning and significance behind events. Related items
emphasized powerful forces working with one's life (paranoia) and the need for
sober intellectual and moral self-scrutiny (humorlessness, conscientousness)."
Were it not for the factual and long known association between
depersonalization and temporal lobe epilepsy, these reports would seem to offer
little more than an interesting similarity in symptomatology. But the equal
similarity in the presenting personality descriptions of patients with
depersonalization disorder and temporal lobe epilepsy would lead to at least
wonder about the possibility of a certain peculiarity in temporal construction or
subtle alteration in ability to process external reality. According to VVaxman and
Geschwind: 1~

The available evidence suggests that spike discharges in the temporal lobe and
related structures may have preformed effects on behavior. For example, there is
evidence that amygdaloid activity may modulate the secretion of gonadotrophin and
adrenocorticotrophin (Eleftherious et.al. 17, Zolovick18) and that gonadal hormones
in turn alter neural thresholds invoking the amygdala and rhinencephalic pathways
(Kawakami and Sawyer19). Experimental evidence also suggests differential
facilitating and inhibitory effects on stimulation of various regions within the
amygdala on hypothalamically elited behavior in cats (Egger and Flynn2°). On the
basis of these and similar finds, we might in theory expect temporal lobe stimulation
to alter limbic function in a relatively immediate fashion.
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E.M. TORCH

The implication of this highly interesting theoretical association is not that there
is a direct correlation between temporal lobe disorder and depersonalization per
se, but that perhaps there is a particular neural substrate which could make one
more reliable to experience these particular symptoms, and that a constant
discharge from a temporal lobe focus into the limbic system could alter perception
of the conjunction between an external event and its "properly quantitative"
elicited emotional reaction. Certainly depersonalization is present in so many
other settings that one would be highly remiss in hssuming a point to point
concurrence; the issue of lateralization, much less than of cerebral lesion focus
and particular corresponding disorder, is still very much open to debate. And the
presentation of temporal lobe epilepsy and depersonalization syndrome is
dissimilar in important respects (Roth and Harper 21) among them lack of
episodes of unconsciousness in the great majority of depersonalization patients,
sex incidence, age of onset, incidence of serious illnesses anf family history. But
on the basis of the close similarity of the reported behavioral pattern of many
temporal lobe epileptics and that of many patients with depersonalization
syndrome, it would seem that there is at least enough evidence to merit the strong
suspicion of an association between a particular temporal substrate and
syndrome occurrence. The term substrate is, of course, not at all encased within
the confines of abnormality, and may reflect a sharpening of classically left
temporal, more "analytical" modes of handling a particular conflict.22

OBSESSIONALISM

In a previous study the author s attempted to posit a link between

obsessionalism and depersonalization, based on the hypothesis that
depersonalization was significantly based in a repetitive tendency towards self
observation, i.e. an episode of unreality feelings in a particular type of obsessive
personality could lead to a repetitive experience of this feeling as an obsessional
focus. Repeated experiences of this type could result in an episode of
depersonalization. Alternatively, but not far removed from this hypothesis, is the
theoretical possibility that even without the intrustion of a particular set of
unreality feelings, a type of obsessional (ruminative) thought, with the "seIf" as
the content, could lead to feelings of depersonalization, based on the ephemeral
and existential quandries confronting the determined explorer of essential
meanings of self. The ramifications of these hypotheses are not as esoteric or
specialized as they might seem, for one is hard pressed, in treating any patient
with depersonalization, to disallow the obvious drive, intensity and self-scrutiny
present in the syndrome. And in a certain sense, one might say that all neurotic
disorders represent a certain "compulsive reintroduction" of a symptom
experienced by non-neurotic samples. Evidence for an obsessive link in the
syndrome centers on two grounds: psychotherapeutic observations and objective
testing.
The earlier analytic writers often spoke of obsessional characters in their
discussions of depersonalized patients, and even when the term obsession is not
used, the inferences about its presence are strong as in Schilder's 2~ description:
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PSYCHIATRIC QUARTERLY

All depersonalized patients observe themselves continuously and with great zeal;
they compare their present dividedness-within-themselves with their previous
oneness-with-themselves. Self observation is compulsivewith these patients. The
tendency to self-observation continuously rejects the tendency to live, and we may
say it represents the internal negation of experience.

In Skoog's 11 discussion of the subject referenced earlier in this paper, and in

further writings, it becomes clear that the syndrome is at least manifested in a
highly obsessional manner. Skoog further states:

There are several qualitative similarities between depersonalization and anacasms

(Anancastic = insecure, rigid, sensitive, prone to obsessional throught). This
applies particularly to intellectual obsessions, e.g. obsessive doubt and
rumination...the patient does not stop at any fixed anxiety or phobia, he is driven
by his agony to get to the bottom of his experience. In this stage of the onset of
anancasms, depersonalization and obsession merge with one another
phenomenologically, so that the patient in a dizzy paradox experiences both a
feeling of alienation and a reinforced feeling of reality.

Indeed compulsive neurotics can be seen to attempt a "hyperpersonalization"

(Klimes24), as an attempt to make the automatic conscious, leading to a
heightened sense of control and security, (after Sedman25).
In the empirical realm, two classic papers would seem to support a
significant presence of obsessional traits in depersonalized patients, with
Shorvon's 26 series reporting 88% incidence, and R o t h ' s 27 a nearly 75%
incidence of strongly premorbid obsessional traits. Sedman and Reed 28, Sedman
and K e n n a z9 and Videbech 3° all objectively verify a rather insecure personality
with a high degree of obsession and depression present in the premorbid picture
of their depersonalized sample.
It is worthwhile to at least briefly touch on the rather recent literature
concerning the Phobic Anxiety-Depersonalization Syndrome, first enumerated
by Roth 27. There is, in the recent writing on depersonalization, a strong cross
current of patients described as suffering from "depersonalization" who should
more properly be diagnosed, at least as personalities, under Briquet's syndrome,
conversion hysteria or included in the old rubric of hysterical personality. Their
episodes of depersonalization are of a fleeting nature, cause less suffering in and
of themselves, and do not have a lasting quality after the phobic content is in
remission. It can also be observed that very often these people are extremely
agoraphobic, and this chink in the a r m o r causes more difficulty than
depersonalization. There is the additional factor that the syndrome often
responds rapidly and effectively to imipramine (Klein31), which is certainly not
the case in the majority of patients with depersonalization syndrome.
Nevertheless, there is undoubted overlapping because both types of patients
usually possess obsessional patterns of thought and behavior and good evidence
of depressive elements with conjoining anxiety.
While obsessive self scrutiny is not the sine qua non in depersonalization, we
have seen, if not an undeniable link to causation, at least an undeniable presence
of both obsessional personality characteristics and a tendency towards a
continuous and compulsive reliving of the state.
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E.M. TORCH

DEPRESSION

Patients with depersonalization are most often considerably disturbed and

discouraged by the inexplicable turn of events which has overtaken them. tt could
be stated almost routinely, in fact, that the patient who is not disturbed about his
changed state of feelings is a patient misdiagnosed (It is not uncommon,
however, for patients with depersonalizatin of many years standing to develop a
life style which accommodates their disorder, and subsequently not present
themselves for treatment). He may be suffering from another disorder with
fleeting or "wavering" depersonalization phenomena or is perhaps exhibiting a
"forme fruste" of a psychosis.
Therefore, in a great majority of patients, the physician is likely to
encounter a patient with complaints which have a strong depressive edge to them:
" I feel as if I were dead." " W h a t good am I this way?" The line between
depression and depersonalization, at least in the tone and content, seems diffuse.
In addition, patients with depersonalization often seem to speak of "sinking",
"falling", "hopeless voids" and usually have some sort of accompanying
somatic focus such as breathlessness, tachycardia, globus and various aches and
pains. Indeed, there is no more fascinating paradox (in the author's opinion)
than the affective change of affairs in depersonalization syndrome; a decrease in
the ability to experience interest, pleasure or pain, with the mysterious
preservation of such intense concern about this inability, manifested as an almost
morbid fascination.
It is much less difficult to discuss depression as a concurrent or resultant,
rather than etiological, factor in depersonalization syndrome. While many
statistical studies (which will be examined shordy) lend strong credence to the
presence of depression, there are very few, if any, discussions of its etiological
presence. When depression is seen in the etiological summary, there is usually
the impression given in its presentation of " a n already weakened defense
system" or a certain loss of the ability to repress. It is not so difficult a task to
understand how the accompanying changes of depression could make the
individual more prone to eventual depersonalization states. Notable in this regard
could be such depressive equivalents as the previously mentioned somatic
preoccupations, confusion, changes in memory, fatigues, guilt, and rumination.
The purpose of this paper, however, is not to delineate etiological factors, so
much as to demonstrate syndrome configuration, though etiology is strongly
implied in some of the component substantiation. While depression's exact role
in the etiology is still not clear, psychodynamic and empirical literature indicate
that depression would be expected habitually in depersonalization syndrome.
Lion 32, in his discussion of anancastic depressives, spoke of a tendency
towards self observation and stated, '*There are various ways of experiencing this
content which suddenly possessed our patients, as if it were a foreign body that
invaded the organism. They become introspective, and ideas of unreality set in."
In most descriptions of depersonalization, the patient speaks of losing something.
He is in a state of ruminative doubt; he feels incomplete. There is also a
theoretical link 33between hypochondriasis and a primary depression which posits
a somatic focus for feelings of worthlessness or low self-esteem and a strong
relationship to depression.
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Shorvon's 26 patients suffering from depersonalization syndrome had a

strong depressive incidence of 59 % in the previous personality types. Roth 27 had
a similar incidence (53.8 %), but many other patients listed in other categories
gave indications of depressive features, such as ruminative qualities and somatic
complaints. Depression and depersonalization were also strongly linked in the
studies of Skoog 11, Sedman and Reed 28, Sedman and Kenna 29, Davison 13,
Videbech 3°, Brauer et al?4, and interestingly, formed the seminal factor in
Kenna and Sedma's t3 study of depersonalization in temporal lobe epilepsy and
the organic psychoses.
As a final point, all of the papers referenced above have another factor in
common; additional conjunctions of obsessionalism and depression appearing at
the same place at the same time (e. g. where depersonalization was found). While
using this fact to imply a necessary presence of both would be rather circumstantial
and perhaps circular, it is interesting that even when the gist of the research was
involved in separating obsessionalism from depersonalization, depressive control
groups often ended up closely paralleling depersonalized control groups in
improvement rate. For example, in Sedman's 25 study, he points out that his
results indicate "that the depersonalized subjects report in addition many
depressive symptoms, as reflected in the high scores on the Beck Inventory.
When the subjects improved and became non-depersonalized, depression of
mood score decreased significantly."
Perhaps the obsessional patient with depersonalization represses depressive
feelings, hence being aware only of thought. By the very nature of the repression,
a dysequilibrium in feeling occurs, but the depression is not in conscious recall.
To maintain compensation, the patient must cope with the depressive affect with
further repression--i.e, a dissociation from the "feeling self" which is now
witnessed by an "observing ego". But the observing ego is using intellectual
means of dealing with the problem, because the affect is simultaneously repressed
from consciousness. The analytic construction is quite prominent in literature
linking depersonalization and depression.

PERSISTENCE

The final component which would seem to be almost a priori in the

configuration would be that of repetition, or persistence. While this would seem
to be stating a redundancy in view of the lengthy mention made of obsessional
factors, there is some separation needed, if for no other reason than the obstinate,
almost willed nature of resistance shown by the depersonalized patient. While we
have seen that there would be more than enough reason to expect that the
obsessional, sometimes depressive character would be more than a match for the
most tolerant and empathetic psychiatrist, one must still ask how a syndrome can
run a steady course with such intensity for so long a period of time. There are
many reports of symptom durations of twenty to thirty years. Several
psychoanalysts have written that at least five years of work are necessary before
one begins to think of remission. In speaking of treatment for a moment, even
the chemotherapuetic regimens are tinged with an element of the arcane, with
prominent authorities recommending abreaction or amphetamines. Can we
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E.M. TORCH

explain, m e r e l y by resorting to the obsessional elements of the illness, the oft-

found time c o n s u m i n g a n d fruitless therapies a t t e m p t e d ? Even m a k i n g reference
to the p r e f o r m e d or organic n a t u r e of the s y n d r o m e will not seem to explain
chronicity, for as p o i n t e d out previously, a large p r o p o r t i o n o f the n o r m a l
p o p u l a t i o n has h a d a transitory experience of unreality feelings.
T h e answer, the a u t h o r feels, lies not in the process itself (although the
insecure obsessive is p r o n e to r u m i n a t e in o r d e r to get to the b o t t o m of things).
After reviewing the literature a n d e x a m i n i n g m a n y of these individuals, one is
led, after a time, to give the content of the p r e o c c u p a t i o n m o r e i m p o r t a n c e t h a n
would o r d i n a r i l y be c u s t o m a r y . F o r in m a n y ways this content, o r the obvious
conclusions d r a w n from it, are those issues which would seem to puzzle m a n in
a n y state o f rationality. T h e a u t h o r feels that there is a ptace in this p a r t i c u l a r
scientific e n d e a v o r for at least a m o d i c u m of philosophical questioning. After all,
the d e p e r s o n a l i z e d patient, as an e n d result of his d i l e m m a , faces a p r o b l e m
which is a universal one. H e has lost the ability to put off the q u e s t i o n , " W h a t a m
I in essence? W h e n I can no longer lose myself in the m a i n s t r e a m of life, when I
can not forget that I a m rather existentially alone, what a m I m a d e of?." O n e can
liken the depersonalized patient to a person on a desert island who r e m a i n s fully
sane but is unable to decathect a n y experience. Certainly, most of us have asked
these same questions at one time or another, but the fact r e m a i n s that there are
no firm answers to them. If we were obsessional, a n d d e t e r m i n e d e n o u g h to find
the answer, we too, might experience these feelings of unreality.
T h e m a i n point in the foregoing discussion is that the content of the
obsession is a real philosophical d i l e m m a in itself, a n d as such can easily add all of
the fuel that the fire needs, so to speak, to an individual who tries to enter into the
m a i n s t r e a m of living. W h a t m a n y psychiatrists find themselves unwittingIy
doing, after a time, is a t t e m p t i n g to aid the d e p e r s o n a l i z e d patient in the hopeless
task of either finding the answers or forgetting he ever b e g a n to look.

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