Feeling Unreal: Depersonalization Disorder and the Loss of the Self

Perhaps some readers will recall a game played in adolescence: think of a word. Repeat it over and over in one’s mind until it loses meaning. Then, as the word itself loses meaning, the world around does the same, accompanied by a not totally unpleasant feeling of being unreal. This is the experience of depersonalization.

I say, not totally unpleasant, because the player, as opposed to a patient with depersonalization disorder, remains in control and returns to his or her usual state—one in which the player simply feels himself, a return from a self-induced feeling of unreality. Spiegel (1) once proposed, in a closely reasoned psychoanalytic paper, that the self, a collection of many self-representations, acts as a steadying flywheel operating out of awareness, ordinarily providing homeostasis and buffering against transient alterations of self-feeling, thereby keeping us feeling real without our even knowing or recognizing it. Only when there is a disturbance of that steady state do we sense an alteration; we then feel unreal—the subject of this book.

In nine chapters, an epilogue, and a review of frequently asked questions, the authors lead the reader through descriptions of depersonalization culled from scientific and literary presentations of the past century and a half. Chapters are devoted to diagnosis (adhering to the criteria for depersonalization disorder in the DSM-IV), clinical research, the biology of depersonalization, and treatment (both medication and psychotherapy). Although this outline might sound dry as dust, the book is anything but that. Many case summaries are offered, which put into words the seemingly ineffable state that is depersonalization. Through frequent quotation of patients, the reader is gradually led to sense and feel the experience of losing a sense of self, of what it means to feel unreal while retaining an intact capacity for reality testing. I believe that the first two chapters in particular (“Strangers to Our Selves” and “Expressions of the Inexpressible”) would be useful to patients trying to comprehend their experience. The authors quote the 19th-century diarist Amiel as stating, “All is strange to me; I am, as it were, outside my own body and individuality; I am depersonalized, detached, cut adrift. Is this madness?” Patients will identify with him. Reading these chapters, in concert with the help of the treating psychiatrist, will help them differentiate depersonalization from psychosis, relieving an important fear.

A question may be raised as to the audience for this book. Some chapters, as noted above, seem to be written with the patient in mind. Others, focusing on biology, clinical research, and treatment, would seem to have the professional in mind. Chapter 9 especially, on psychotherapeutic treatment, is a small gem for professionals. It details the brief 10-session psychotherapy developed at Mount Sinai Hospital in New York for the treatment of depersonalization disorder and provides commentary on an actual session-by-session treatment of a patient. Any therapist working with a patient with depersonalization would benefit from a careful study of that chapter.

The authors implicitly raise the problem of clinical diagnosis. As described in DSM-IV, DSM is a categorical scheme “that divides mental disorders into types based on criteria sets with defining features” (p. xxii). This method works best when the categories are clearly homogeneous without blurring at the boundaries. Sometimes we cannot be sure that the category is discrete with “absolute boundaries dividing it from other mental disorders or from no mental disorder.” It may lie along a continuum. One strength of Feeling Unreal is the categorical approach taken by the authors. By selecting a population with DSM-IV depersonalization disorder with clearly defined boundaries, the authors were able to present their own research, compare it to the research of others, illustrate methods of diagnosis, and demonstrate a very useful therapeutic method for the population that they defined. This very strength is also its weakness, because depersonalization is also a phenomenon, not a strict diagnostic category, in which feeling real at times is disrupted by feeling unreal. It is this extended population that Spiegel (1), Jacobson (2), Abend (3), and Frances et al. (4), among others, have studied. Reading this useful and interesting book makes it clear that each approach has its place.

The book could have been better edited by the publisher. There are errors in the number references to the chapter endnotes. Some psychiatrists are referred to as psychologists, and there is at least one important error in the references text.