36 - Depersonalisation

Depersonalisation:

© SPMM Course conversion symptom not delusional as the husband does not think he is pregnant! Pseudocyesis is a condition where a woman experiences clinical signs of pregnancy without being pregnant, and the patient is convinced of pregnancy. Koro is a culture-bound anxiety state where the patient believes that his penis is shrinking into his abdomen, and he will die as a result. This is considered to be a desomatization (organ specific depersonalization) experience associated with folk beliefs (hence not a delusion as culturally relevant). It is seen in Malaysia and Singapore. In multiple personality disorders, one-way amnesia is common. (A knows B’s existence, B is not aware). Possession states can occur as a part of dissociation or in normal religious experiences, or under hypnosis. Possession states, where consciousness is preserved, can occur in schizophrenia. Consciousness is altered in dissociative states. Lycanthropy is a form of possession where the patient loses awareness and identity and believes he has been transformed into an animal, usually wolf. Out of body experiences, autoscopy, depersonalisation and transcendental experiences are clustered often in Near Death Experiences. The neurophysiological basis of near death experience (NDE) is unknown. Clinical observations suggest that REM state intrusion contributes to NDE. REM intrusion during wakefulness is a frequent normal occurrence and NDE elements can be explained by REM intrusion. A feeling of impending ego dissolution is noted in LSD intoxication. Depersonalisation: It is the third most common symptom in psychiatric clinics. It is defined as a change in self-awareness and the individual feels as if he is unreal. The ‘as if’ quality differentiates it from psychotic states. When a similar feeling occurs for objects and environment around an individual, it is termed as derealization (Mapother). It is always subjective, unpleasant with affective change invariably, and insight preserved. Emotional numbing, loss of feelings of agency and self-esteem, disturbed body image, altered perception of time, memory and sensory experiences of all modalities are reported. Temporal lobe epilepsy (lasts for minutes), hysterical dissociation, depression, any anxiety state (lasts for seconds) including anankastic personality, using tricyclic antidepressants, hallucinogens and cannabis can cause depersonalisation apart from fatigue or meditation/yoga in normal people. ECT can worsen depersonalisation by unknown mechanisms. In psychiatric population, the affect associated with the experience is extremely unpleasant as opposed to the normal population. The most common psychiatric diagnosis is depression followed by anxiety disorders. Dissociation is only infrequently associated. Depersonalisation is often difficult to distinguish from derealization, and they often occur together though the former being commoner. The patients often do not report the symptom as it is difficult to express. This may be related to the pathology of familiarity wherein familiarity of self being lost. Depersonalisation is associated with déjà vu / jamais vu where place familiarity is error prone. Depersonalisation is frequently situational and almost always episodic. In depersonalisation disorder (classified as a dissociative disorder in DSM 4) the experience lasts for hours. Roth described a PAD – Phobic anxiety depersonalisation syndrome. Typically a married female in thirties with agoraphobia and anxiety – worsens with ECT treatment. This is now relevant only historically.