Derealization and panic attacks: a clinical evaluation on 150 patients with panic disorder/agoraphobia

An exploration of the antecedents and mechanisms causing athletes' stress and twisties symptom

Research background

Twisties symptoms have attracted the world's attention in the sports field since the 2020 Tokyo Olympics.

Aim

However, studies on the symptoms and causes, inducing mechanisms, and relationships between DP/DR (Depersonalization/Derealization Disorder) and anxiety and depression for athletes have been sparse for both the general population and athletes. The literature on the twisties issue of athletes is quite scarce in the past.

Research method

Adopting the criteria appealing to PRISMA Items to review the subject twisties in a broader mode and combing with the IPO (Input-Process-Output) model for triangulation testing purpose, this study categorized the literature to explore input variables causing athletes' twisties and identified process variables in psychological mechanisms bridging suppression and finally discussed the existing possible ways in helping athletes to solve problems caused by twisties.

Results

The authors formed 6 propositions in summarizing twisties' influential factors and mechanisms and tried to propose solutions to reduce the stress and the relevant twisties symptom of athletes. (1) Promotion of Athletes' Mental Toughness to Resist Stressors. (2) Interventions that correct for cognitive misinterpretations and appropriate relaxation and mindfulness practice in correcting a range of attention might reduce DP/DR. (3) Monitoring the athlete's HRV test results to ensure the Athlete's ability to resist pressure. (4) Avoid organizational stressors. (5) Written Emotional Disclosure method. (6) Improve various support systems for athletes: dual career paths. (7) Athletes' Stressful Awareness about the impact of gender, seniority, and environment.

Conclusion

Through the theoretical dialogue on the symptom of twisties, this study helps promote the development of the research of "twisties" and depersonalization-derealization symptoms (DDS); both have been under-researched.

Coping Motivated Alcohol Use: The Role of Social Anxiety and Dissociation

Background: Social anxiety has been associated with higher rates of negative alcohol use consequences, and this relationship appears to be accounted for by coping drinking motives. Dissociation is commonly present in anxiety disorders, including social anxiety disorder, and may serve to unconsciously reduce negative emotions when more effortful coping strategies are not effective. Objectives: The present study examined whether the relationship between social anxiety, coping motives, and alcohol consequences was moderated by dissociative symptoms. It was hypothesized that coping motives would mediate the relationship between social anxiety and alcohol consequences, and that dissociation would moderate the relationship between social anxiety and coping motives. Undergraduate students who endorsed alcohol use within the past 30 days (n = 320) were recruited from a large public university. Participants completed measures of social anxiety, dissociation, alcohol motives, and alcohol consequences as part of a larger online questionnaire. Results: Coping motives were found to mediate the relationship between social anxiety and alcohol consequences. Dissociation did not moderate the relationship between social anxiety and coping motives. Dissociation was significantly associated with alcohol consequences via coping motives. Conclusions: Future research should include longitudinal research designs or ecological momentary assessment designs and should examine these relationships in clinical and community samples.

Derealization symptoms according to the subjective visual vertical during unilateral centrifugation in patients with type 2 diabetes mellitus

BACKGROUND

A recent study has shown variability on the perception of verticality during unilateral centrifugation among patients with type 2 diabetes mellitus; it is yet unknown if it is related to symptoms of unreality.

OBJECTIVE

In patients with type 2 diabetes mellitus compared to age matched healthy volunteers, to assess depersonalization/derealization (DD) symptoms before and after unilateral centrifugation, according to the subjective visual vertical (SVV).

METHODS

47 patients with type 2 diabetes mellitus and 50 age matched healthy volunteers participated in the study. They replied to standardized questionnaires of symptoms related to balance, depression, and anxiety. Then, after neuro-otological evaluation, they completed a DD inventory before and after unilateral centrifugation (300°/s, 3.85 cm) with SVV estimation.

RESULTS

Right/left asymmetric SVV during centrifugation was identified in 17 patients (36%) and no SVV change during centrifugation was identified in 6 patients (13%). Before centrifugation, patients with asymmetric SVV already reported some of the DD symptoms, while patients with no SVV change reported almost no DD symptoms. Unilateral centrifugation provoked an increase of DD symptoms in both healthy volunteers and the entire group of patients (repeated measures ANOVA, p < 0.01), except in the 6 patients with no SVV change. Before centrifugation, the DD score showed influence from the SVV subgroup and the evidence of depression (MANCoVA, p < 0.01); after centrifugation, which provoked asymmetry of the right/left utricular input, only the influence from depression persisted. No influence was observed from the characteristics of the subjects, including retinopathy, peripheral neuropathy (assessed by electromyography) or weight loss, or from the total score on the questionnaire of symptoms related to balance.

CONCLUSIONS

In patients with type 2 diabetes mellitus and healthy volunteers, utricular stimulation by unilateral centrifugation may provoke DD symptoms, with an influence from depression. The results support that the aphysiological utricular input given by unilateral centrifugation may contribute to create a misleading vestibular frame of reference, giving rise to 'unreal' perceptions.

Neuromolecular basis of faded perception associated with unreality experience

Perceptual changes in shape, size, or color are observed in patients with derealization symptoms; however, the underlying neural and molecular mechanisms are not well understood. The current study explored the relationship between neural activity associated with altered colorfulness perception assessed by fMRI and striatal dopamine D₂ receptor availability measured by [¹¹C]raclopride PET in healthy participants. Inside an fMRI scanner, participants performed the saturation adaptation task, where they rated how much vivid/faded visual objects looked like real/unreal ones using a visual analog scale. We found that participants experienced greater unreality when they perceived fadedness than vividness despite physically identical saturation. The combined fMRI and PET analyses revealed that the faded perception-related activities of the dorsolateral prefrontal and parietal cortex were positively correlated with striatal D₂ receptor availability. This finding may help to understand the neuromolecular mechanisms of faded perception associated with feeling unreal in derealization symptoms.

Derealization during utricular stimulation

BACKGROUND

Feelings of unreality have been provoked in healthy subjects undergoing stimulation of the semicircular canals, but no studies have assessed the influence of otoliths stimulation on depersonalization/derealization (DD) symptoms.

OBJECTIVE

To assess DD symptoms during unilateral centrifugation in healthy adults.

METHODS

100 subjects participated in the study. They completed a standardized questionnaire of symptoms related to balance (Jáuregui-Renaud 2003), the 17-item Hamilton Depression Rating Scale, the Zung Instrument for Anxiety Disorders and the Cox & Swinson 28-item DD inventory. After unilateral centrifugation (300°/s at 3.5 cm), subjects completed the DD inventory again.

RESULTS

Centrifugation provoked symptoms which subjects denied ever experiencing before. The items most frequently reported were "Body feels strange or different in some way" (56%) and "Time seems to pass very slowly" (55%). The DD total score was related to the score of symptoms related to balance and to the depression inventory with no influence from the general characteristics of the subjects or the responses to vestibular tests. The individual scores of symptoms of vestibular function and derealization were related to the report of the other DD symptoms.

CONCLUSIONS

In healthy subjects, unilateral centrifugation provokes DD symptoms. The results support that distorted vestibular signals may create a misleading frame of reference which mismatch with the other senses, giving rise to 'unreal' perceptions.

Depersonalisation disorder: clinical features of 204 cases

Background

Depersonalisation disorder is a poorly understood and underresearched syndrome.

Aims

To carry out a large and comprehensive clinical and psychopathological survey of a series of patients who made contact with a research clinic.

Method

A total of 204 consecutive eligible referrals were included: 124 had a full psychiatric examination using items of the Present State Examination to define depersonalisation/derealisation and 80 had either a telephone interview (n=22) or filled out a number of self-report questionnaires. Cases assessed were diagnosed according to DSM–IV criteria.

Results

The mean age of onset was 22.8 years; early onset was associated with greater severity There was a slight male preponderance. The disorder tended to be chronic and persistent. Seventy-one per cent met DSM–IV criteria for primary depersonalisation disorder. Depersonalisation symptom scores correlated with both anxiety and depression and a past history of these disorders was commonly reported. ‘Dissociative amnesia’ was not prominent.

Conclusions

Depersonalisation disorder is a recognisable clinical entity but appears to have significant comorbidity with anxiety and depression. Research into its aetiology and treatment is warranted.

What is nausea? A historical analysis of changing views

The connotation of "nausea" has changed across several millennia. The medical term 'nausea' is derived from the classical Greek terms ναυτια and ναυσια, which designated the signs and symptoms of seasickness. In classical texts, nausea referred to a wide range of perceptions and actions, including lethargy and disengagement, headache (migraine), and anorexia, with an awareness that vomiting was imminent only when the condition was severe. However, some recent articles have limited the definition to the sensations that immediately precede emesis. Defining nausea is complicated by the fact that it has many triggers, and can build-up slowly or rapidly, such that the prodromal signs and symptoms can vary. In particular, disengagement responses referred to as the "sopite syndrome" are typically present only when emetic stimuli are moderately provocative, and do not quickly culminate in vomiting or withdrawing from the triggering event. This review considers how the definition of "nausea" has evolved over time, and summarizes the physiological changes that occur prior to vomiting that may be indicative of nausea. Also described are differences in the perception of nausea, as well as the accompanying physiological responses, that occur with varying stimuli. This information is synthesized to provide an operational definition of nausea.

Sleep loss increases dissociation and affects memory for emotional stimuli

BACKGROUND AND OBJECTIVES

Because of their dreamlike character, authors have speculated about the role that the sleep-wake cycle plays in dissociative symptoms. We investigated whether sleep loss fuels dissociative symptoms and undermines cognitive efficiency, particularly memory functioning.

METHODS

Fifty-six healthy undergraduate students were randomly assigned to an experimental group (n = 28) and a control group (n = 28). The experimental group was deprived of sleep for 36 h in a sleep laboratory; the control group had a regular night of sleep. Sleepiness, mood, and dissociative symptoms were assessed 6 times in the experimental group (control group: 4 times). Several cognitive tasks were administered.

RESULTS

Sleep deprivation led to an increase in dissociative symptoms, which was mediated by levels of general distress. Feelings of sleepiness preceded an increase of dissociative symptoms and deterioration of mood. Finally, sleep loss also undermined memory of emotional material, especially in highly dissociative individuals.

LIMITATIONS

Limitations included moderate reliability of the mood scale, limited generalizability due to student sample, and a relatively short period of intensive sleep deprivation rather than lengthy but intermittent sleep loss, representative of a clinical population.

CONCLUSIONS

We found that sleep deprivation had significant effects on dissociation, sleepiness, and mood. Specifically, sleepiness and dissociation increased during the night, while mood deteriorated. Our findings stress the importance of sleep deficiencies in the development of dissociative symptoms. They support the view that sleep disruptions fuel distress, but also degrade memory and attentional control. It is against this background that dissociative symptoms may arise.

Symptom profiles in depersonalization and anxiety disorders: an analysis of the Beck Anxiety Inventory

BACKGROUND

Depersonalization disorder (DPD) entails distressing alterations in self-experiencing. However, it has long been recognized that depersonalisation symptoms occur in other disorders, particularly anxiety and panic. One strand of research proposes that depersonalization phenomenology arises through altered autonomic arousal in response to stress.

SAMPLING AND METHODS

We sought to examine profiles of anxiety symptoms through a secondary data analysis of individual items and factor subscales on the Beck Anxiety Inventory (BAI), comparing two relatively large patient samples with DPD or with a variety of anxiety conditions, respectively. The DPD sample (n = 106) had a lower overall BAI score than the combined anxiety disorders group (n = 525).

RESULTS

After controlling for this as well as for potential confounders such as age and gender, the DPD group presented significantly lower scores on the panic subscale, marginally lower scores on the autonomic subscale and significantly higher scores on the neurophysiological subscale of the BAI.

CONCLUSIONS

These differences imply similarities between the cognitive components of DPD and anxiety disorders while physiological experiences diverge. The findings encourage future research looking at direct physiological measures and longitudinal designs to confirm the mechanisms underlying different clinical manifestations of anxiety.

Vestibular Function and Depersonalization/Derealization Symptoms

Patients with an acquired sensory dysfunction may experience symptoms of detachment from self or from the environment, which are related primarily to nonspecific symptoms of common mental disorders and secondarily, to the specific sensory dysfunction. This is consistent with the proposal that sensory dysfunction could provoke distress and a discrepancy between the multi-sensory frame given by experience and the actual perception. Both vestibular stimuli and vestibular dysfunction can underlie unreal experiences. Vestibular afferents provide a frame of reference (linear and angular head acceleration) within which spatial information from other senses is interpreted. This paper reviews evidence that symptoms of depersonalization/derealization associated with vestibular dysfunction are a consequence of a sensory mismatch between disordered vestibular input and other sensory signals of orientation.

Childhood Traumatic Experiences, Dissociative Symptoms, and Dissociative Disorder Comorbidity Among Patients With Panic Disorder: A Preliminary Study

This study assessed childhood trauma history, dissociative symptoms, and dissociative disorder comorbidity in patients with panic disorder (PD). A total of 92 psychotropic drug-naive patients with PD, recruited from outpatient clinics in the psychiatry department of a Turkish hospital, were involved in the study. Participants were assessed using the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), Dissociation Questionnaire, Panic and Agoraphobia Scale, Panic Disorder Severity Scale, and Childhood Trauma Questionnaire. Of the patients with PD, 18 (19%) had a comorbid dissociative disorder diagnosis on screening with the SCID-D. The most prevalent disorders were dissociative disorder not otherwise specified, dissociative amnesia, and depersonalization disorders. Patients with a high degree of dissociation symptoms and dissociative disorder comorbidity had more severe PD than those without (p < .05). All of the childhood trauma subscales used were correlated with the severity of symptoms of dissociation and PD. Among all of the subscales, the strongest relationship was with childhood emotional abuse. Logistic regression analysis showed that emotional abuse and severity of PD were independently associated with dissociative disorder. In our study, a significant proportion of the patients with PD had concurrent diagnoses of dissociative disorder. We conclude that the predominance of PD symptoms at admission should not lead the clinician to overlook the underlying dissociative process and associated traumatic experiences among these patients.

Panic symptom clusters differentially predict suicide ideation and attempt

Increasingly strong evidence links anxiety disorders in general and panic attacks in particular to suicidality. The underlying causes and specifics of this relation, however, remain unclear. The present article sought to begin addressing this question by clarifying the association between panic symptoms and suicidality. Data were sampled from the NESARC epidemiological data set from the US and analyzed as four independently, randomly selected subsets of 1000 individuals using structural equation modeling analyses and replicating results across samples. Evidence is presented for four symptom clusters (cognitive symptoms, respiratory distress, symptoms of alpha and beta adrenergic activation) and the differential association of each with suicidal ideation and attempts. Symptoms of alpha adrenergic activation predicted prior suicide attempt whereas cognitive symptoms predicted prior suicidal ideation. These findings were independent of comorbid major depressive disorder. It is suggested that assessment of suicide risk in the community includes the presentation of cognitive symptoms and symptoms related to alpha adrenergic activation.

Anxiety changes depersonalization and derealization symptoms in vestibular patients

Background. Depersonalization and derealization are common symptoms reported in the general population. Objective. The aim of the present study was to establish the relationship between anxiety and depersonalization and derealization symptoms in patients with peripheral vestibular disorders. Methods. Twenty-four vestibular patients with anxiety and 18 vestibular patients without anxiety were examined for depersonalization and derealization symptoms. They were also compared to healthy controls. Results. The results revealed that anxiety consistently changes depersonalization and derealization symptoms in vestibular patients. They are more frequent, more severe, and qualitatively different in vestibular patients with anxiety than in those without anxiety. Conclusion. Anxiety has an effect on depersonalization and derealization symptoms in vestibular patients. The various hypotheses about the underlying mechanism of this effect were discussed.

Depersonalization/derealization during acute social stress in social phobia

The present study aimed at investigating how frequently and intensely depersonalization/derealization symptoms occur during a stressful performance situation in social phobia patients vs. healthy controls, as well as testing hypotheses about the psychological predictors and consequences of such symptoms. N=54 patients with social phobia and N=34 control participants without mental disorders were examined prior to, during, and after a standardized social performance situation (Trier Social Stress Test, TSST). An adapted version of the Cambridge Depersonalization Scale was applied along with measures of social anxiety, depression, personality, participants' subjective appraisal, safety behaviours, and post-event processing. Depersonalization symptoms were more frequent in social phobia patients (92%) than in controls (52%). Specifically in patients, they were highly positively correlated with safety behaviours and post-event-processing, even after controlling for social anxiety. The role of depersonalization/derealization in the maintenance of social anxiety should be more thoroughly recognized and explored.

Depersonalization and personality in panic disorder

BACKGROUND

Prevalence and clinical correlates of depersonalization symptoms have been associated with panic disorder. Personality traits might increase the likelihood of experiencing depersonalization symptoms or depersonalization disorder in panic patients.

AIMS

The objectives of this study are to establish the prevalence of depersonalization symptoms during the panic attack and in depersonalization disorder and to examine the personality factors associated with the presence of depersonalization in patients with panic disorder.

METHODS

The sample comprised 104 consecutive adult outpatients with panic disorder, diagnosed according to the Semistructured Clinical Interview for DSM-IV (Axis I/II disorders). Participants were assessed with the Cambridge Depersonalization Scales, the Temperament and Character Inventory, and the Panic and Agoraphobia Scale.

RESULTS

Forty-eight percent of the sample had depersonalization symptoms during the panic attack, whereas 20% of patients had a depersonalization disorder. Women presented more depersonalization disorders than did men (P = .036). Patients with panic disorder with depersonalization disorder had a more severe panic disorder (P = .002). Logistic regression analysis showed that self-transcendence trait (odds ratio, 1.089; 95% confidence interval, 1.021-1.162; P = .010) and severity of panic (odds ratio, 1.056; 95% confidence interval, 1.005-1.110; P = .032) were independently associated with depersonalization disorder.

CONCLUSIONS

A high prevalence of depersonalization symptoms and depersonalization disorder was confirmed in patients with panic disorder, supporting a dosage effect model for understanding depersonalization pathology. Self-transcendence trait and severity of panic disorder were reported as risk factors for depersonalization disorder.

[Depersonalisation/derealization - clinical picture, diagnostics and therapy]

The present state of knowledge about depersonalization (DP) and derealization (DR) is reviewed with respect to classification, epidemiology, etiology, and therapy. Mild and transient DP-DR are considered to be common phenomena. The prevalence of depersonalization-derealization disorder (DP-DR-D) is estimated to be approx. 1-2% of the general population in the Western hemisphere. DP-DR-D is probably severely underdiagnosed. DP-DR-D is strongly associated with depression and anxiety disorders. It is suggested that symptoms of DP-DR indicate disease severity and negatively predict therapy outcome. Neurobiological and psychological models have shown that a disordered body schema and emotional and autonomic blunting are essential components of the disorder. Despite the frequency of DPDR and its clinical relevance, there is a considerable lack of empirical research on DP-DR with respect to the health-care situation of depersonalized patients and with regard to treatment options.

Clinical correlates of depersonalization symptoms in patients with bipolar disorder

BACKGROUND

Prevalence and clinical correlates of dissociative symptoms in general, and depersonalization (DP) in particular, in patients with mood disorders have received limited attention in the literature. Nevertheless, the identification of these symptoms may have important implications in terms of a better definition of clinical endophenotypes. Thus, this study aimed at investigating frequency and clinical correlates of dissociative symptoms, with special attention to DP symptoms, in patients with bipolar disorder (BD) looking specifically at differences between BD-I and BD-II and the comorbidity with panic disorder.

METHODS

The study sample included 91 adult patients with BD (BD-I=43; BD-II=48) assessed with the Semi-structured Clinical Interview for Temperament (TEMPS-I), the Dissociative Experiences Scale (DES) and the Structured Clinical Interview for Depersonalization-Derealization Spectrum (SCI-DER).

RESULTS

There was no difference in lifetime dissociative experiences or DP symptoms between BD-I and BD-II patients. There was no difference in relation to temperament characteristics. Lifetime DP symptoms, as assessed with the SCI-DER, were associated to an early onset of the BD (beta=-0.436, t=-4.572, p<0.001). Derealization symptoms correlated with panic disorder comorbidity (OR=1.22; 95%CI=1.03-1.46, Wald=5.177, p=0.023).

CONCLUSIONS

Our study suggests that lifetime DP symptoms are correlated with an early onset of the BD and derealization symptoms with panic disorder comorbidity, bearing the opportunity to identify patients with a specific profile for a better clinical and neurobiological definition.

The structure of lifetime panic-agoraphobic spectrum

The heterogeneity of the clinical presentation of panic disorder (PD) has prompted researchers to describe different subtypes of PD, on the basis of the observed predominant symptoms constellation. Starting from a dimensional approach to panic disorder, an instrument to assess lifetime panic-agoraphobic spectrum (PAS) available in interview or self-report form (SCI-PAS, PAS-SR) was developed which proved to have sound psychometric properties and the ability to predict delayed response to treatment in patients with mood disorders. However, the structure of the instrument was defined a priori and an examination of its empirical structure is still lacking. Aim of the present report is to analyse the factor structure of the PAS taking advantage of a large database of subjects with panic disorders (N=630) assessed in the framework of different studies. Using a classical exploratory factor analysis based on a tetrachoric correlation matrix and oblique rotation, 10 factors were extracted, accounting overall for 66.3% of the variance of the questionnaire: panic symptoms, agoraphobia, claustrophobia, separation anxiety, fear of losing control, drug sensitivity and phobia, medical reassurance, rescue object, loss sensitivity, reassurance from family members. The first two factors comprise the DSM-IV criteria for panic disorder and agoraphobia. The other factors had received limited empirical support to date. We submit that these symptoms profiles might be clinically relevant for tailoring drug treatments or psychotherapeutic approaches to specific needs. Future perspectives might include the use of these factors to select homogeneous subgroups of patients for brain-imaging studies and to contribute to elucidating the causes and pathophysiology of panic disorder at molecular level.

Validity and reliability of the Structured Clinical Interview for Depersonalization-Derealization Spectrum (SCI-DER)

This study evaluates the validity and reliability of a new instrument developed to assess symptoms of depresonalization: the Structured Clinical Interview for the Depersonalization-Derealization Spectrum (SCI-DER). The instrument is based on a spectrum model that emphasizes soft-signs, sub-threshold syndromes as well as clinical and subsyndromal manifestations. Items of the interview include, in addition to DSM-IV criteria for depersonalization, a number of features derived from clinical experience and from a review of phenomenological descriptions. Study participants included 258 consecutive patients with mood and anxiety disorders, 16.7% bipolar I disorder, 18.6% bipolar II disorder, 32.9% major depression, 22.1% panic disorder, 4.7% obsessive compulsive disorder, and 1.5% generalized anxiety disorder; 2.7% patients were also diagnosed with depersonalization disorder. A comparison group of 42 unselected controls was enrolled at the same site. The SCI-DER showed excellent reliability and good concurrent validity with the Dissociative Experiences Scale. It significantly discriminated subjects with any diagnosis of mood and anxiety disorders from controls and subjects with depersonalization disorder from controls. The hypothesized structure of the instrument was confirmed empirically.

Dissociative experiences differentiate bipolar-II from unipolar depressed patients: the mediating role of cyclothymia and the Type A behaviour speed and impatience subscale

BACKGROUND

Dissociative symptoms are often seen in patients with mood disorders, but there is little information on possible association with subgroups and temperamental features of these disorders.

METHODS

The Dissociative Experience Scale was administered to 85 patients with a DSM-IV Major Depressive Disorder (MDD) or Bipolar-II Disorder (BP-II). Both broad-spectrum dissociation (DES total score) and clearly pathological forms of dissociation (DES-Taxon) were assessed. Temperament was assessed using Akiskal and Mallya;s criteria of Affective Temperaments and the Jenkins Activity Survey (JAS) for Type A Behaviour.

RESULTS

Sixty-five patients gave valid answers to DES. The mean DES and DES-T scores were higher in BP-II (16.8 and 12.7 respectively) compared to MDD (9.0 and 5.7); DES odds ratio (OR)=1.58 (95% CI 1.15-2.18) and DES-T OR=1.60 (95% CI 1.14-2.25) using univariate logistic regression analyses. There was no significant difference in DES score in patients with (n=30) and without an affective temperament (n=35): mean (95% CI), 13.5 vs. 10.5 (-7.8 to 1.9), p=0.224. However the subgroup with a cyclothymic temperament (n=18) had higher DES scores (mean (95% CI): 17.8 vs. 9.7 (2.9-13.3), p=0.003), compared to patients without such a temperament. There was no significant difference in DES scores for patients with (n=35) or without (n=28) a Type A behaviour pattern (JAS>0): mean (95% CI) 12. 7 vs. 10.9 (-6.8 to 3.3), p=0.491), but a positive JAS factor S score (speed and impatience subscale) was associated with significantly higher DES scores than a negative S-score: mean (95% CI) 14.9 vs. 9.0 (1.1-10.7), p=0.017), and this was still significant (p=0.005) using multiple linear regression of DES scores vs. the JAS subscale scores. DES-T scores were significantly higher in patients with OCD (n=9) (mean (95% CI) 18.4 vs. 6.6 (6.0-17.7), p<0.001); eating disorder (n=13) (14.0 vs. 6.8 (1.8-12.6), p=0.009), psychotic symptoms during depressions (n=9) (16.6 vs. 6.9 (3.7-15.8), p=0.002), and in those with a history of suicide attempt (n=28) (11.9 vs. 5.4 (2.2-10.8), p=0.003), but only OCD was an independent predictor after multiple linear regression of DES-T scores vs. all co-morbid disorders (p=0.043).

LIMITATIONS

The major limitation of the present study is a non-blind evaluation of affective diagnosis and temperaments, and assessment in a non-remission clinical status.

CONCLUSIONS

Dissociative symptoms measured with the Dissociative Experience Scale are associated with bipolar features, using formal DSM-IV criteria, cyclothymic temperament and the speed and impatience subscale of the JAS.

Depersonalization and individualism: the effect of culture on symptom profiles in panic disorder

It has been proposed that highly individualistic cultures confer vulnerability to depersonalization. To test this idea, we carried out a comprehensive systematic review of published empirical studies on panic disorder, which reported the frequency of depersonalization/derealization during panic attacks. It was predicted that the frequency of depersonalization would be higher in Western cultures and that a significant correlation would be found between the frequency of depersonalization and individualism scores of the participant countries. As predicted, the frequency of depersonalization during panic was significantly lower in nonwestern countries. There was also a significant correlation between frequency of depersonalization and Individualism (rho = 0.68, p < 0.0001), and between fears of losing control (rho = 0.57, p = 0.005) and individualism. These findings are interpreted in light of recent studies suggesting that individualistic cultures are characterized by hypersensitivity to threat and by an external locus of control. Two features may be relevant in the genesis of depersonalization.

Dissociation and serenity induction

Dissociation is a common experience during or immediately after a traumatic event; yet, most of the current knowledge regarding dissociation is retrospective in nature. The aim of the present study investigated a non-pharmacological method of dissociative induction with a clinical sample. Participants with PTSD and non-trauma exposed participants were randomly assigned to receive either a dissociative induction, or a serenity induction, based on modified Velten mood induction procedures. Participants receiving the dissociative induction reported higher state-dissociation than those receiving the serenity induction. The PTSD group reported greater state dissociation than the non-trauma exposed group, regardless of induction. State dissociation was related to trait dissociation, PTSD severity, and depression. The present results provide an initial demonstration of the viability for inducing state dissociation in the laboratory with a PTSD sample.

The neurobiology and clinical significance of depersonalization in mood and anxiety disorders: a critical reappraisal

Depersonalization and derealization occur on a continuum of situations, from healthy individuals to a severely debilitating disorder where the symptoms can persist chronically. Since 1960s, different neurobiological models have been hypothesized and they have been associated with the temporal lobes. Recent advances in the functioning of the limbic system and the application of Geschwind's concept of disconnection in the cortico-limbic networks, pointed the role of the amygdala and its connections with medial prefrontal cortex and anterior cingulate cortex, the same structures that are strictly interlinked with the neurobiology of emotions and affective disorders. In this paper, we hypothesize that depersonalization may represent a clinical index of disease severity, poorer response to treatment and high level of comorbidity, in mood and anxiety disorders, discussing the neurobiology of depersonalization and the available clinical evidence.

Effect of Dissociative Experiences on Drug Treatment of Panic Disorder

BACKGROUND AND OBJECTIVE

Dissociative experiences are widespread among patients with panic disorder and have a negative impact on cognitive-behavioural therapy. In this study we aimed to investigate whether or not dissociative experiences affect response to drug treatment for panic disorder.

METHODS

Thirty-five patients, 20 women and 15 men, with a mean age of 35.4 years and a diagnosis of panic disorder, were enrolled in the study. Paroxetine 20 mg/day was administered over 6 weeks. Patients were assessed on the Dissociative Experience Scale (DES) and Panic and Agoraphobia Scale (PAS) at the commencement of therapy, and on the PAS again after therapy.

RESULTS

The average DES score was determined as 30.3. Agoraphobia was identified in 34.3% of patients. DES scores were higher in patients with agoraphobia than in those without agoraphobia. Agoraphobia scores were higher in patients with high DES scores. When patients were divided into those with low DES scores (< or =30) and those with high DES scores (>30), a decrease in PAS scores with treatment was observed in both groups, but the decrease was greater in those with low DES scores (18.8 +/- 6.8 vs 5.7 +/- 5.7 in the high-DES score group; Z = 4.486, p = 0.00000053). Similarly, while a decrease in PAS scores with treatment was observed both in patients with agoraphobia (p < 0.05) and in those without agoraphobia, PAS scores decreased more in non-agoraphobic patients (16.7 +/- 7.5 vs 4.8 +/- 6.6 in patients with agoraphobia; Z = 3.799, p = 0.000047). In addition, the decrease in PAS scores was significantly correlated with baseline DES score (beta = 0.706, T = 5.727, p = 0.0000022).

CONCLUSION

This study shows that dissociative experiences reduce the response to drug therapy in patients with panic disorder.

Recovered memory and the Daubert criteria: recovered memory as professionally tested, peer reviewed, and accepted in the relevant scientific community

Research during the past two decades has firmly established the reliability of the phenomenon of recovered memory. This review first highlights the strongest evidence for the phenomenon itself and discusses the survey, experimental, and biological evidence for the varying mechanisms that may underlie the phenomenon. Routes to traumatic amnesia from dissociative detachment (loss of emotional content leading to loss of factual content) and from dissociative compartmentalization (failure in integration) are discussed. Next, an argument is made that false memory is a largely orthogonal concept to recovered memory; the possibility of one phenomena is largely irrelevant to the potential for the other. Furthermore, some aspects of the false memory research offer supportive data for the recovered memory researcher. Finally, the issue of error rates in making the Daubert case is explored. It is concluded that the weight of the evidence should allow the recovered memory victim to come before the court.

Depersonalisation/derealisation symptoms in vestibular disease

BACKGROUND

Depersonalisation is a subjective experience of unreality and detachment from the self often accompanied by derealisation; the experience of the external world appearing to be strange or unreal. Feelings of unreality can be evoked by disorienting vestibular stimulation.

OBJECTIVE

To identify the prevalence of depersonalisation/derealisation symptoms in patients with peripheral vestibular disease and experimentally to induce these symptoms by vestibular stimulation.

METHODS

121 healthy subjects and 50 patients with peripheral vestibular disease participated in the study. For comparison with the patients a subgroup of 50 age matched healthy subjects was delineated. All completed (1) an in-house health screening questionnaire; (2) the General Health Questionnaire (GHQ-12); (3) the 28-item depersonalisation/derealisation inventory of Cox and Swinson (2002). Experimental verification of "vestibular induced" depersonalisation/derealisation was assessed in 20 patients and 20 controls during caloric irrigation of the labyrinths.

RESULTS

The frequency and severity of symptoms in vestibular patients was significantly higher than in controls. In controls the most common experiences were of "déjà vu" and "difficulty in concentrating/attending". In contrast, apart from dizziness, patients most frequently reported derealisation symptoms of "feel as if walking on shifting ground", "body feels strange/not being in control of self", and "feel 'spacey' or 'spaced out'". Items permitted discrimination between healthy subjects and vestibular patients in 92% of the cases. Apart from dizziness, caloric stimulation induced depersonalisation/derealisation symptoms which healthy subjects denied ever experiencing before, while patients reported that the symptoms were similar to those encountered during their disease.

CONCLUSIONS

Depersonalisation/derealisation symptoms are both different in quality and more frequent under conditions of non-physiological vestibular stimulation. In vestibular disease, frequent experiences of derealisation may occur because distorted vestibular signals mismatch with the other sensory input to create an incoherent frame of spatial reference which makes the patient feel he or she is detached or separated from the world.

[Depersonalization--current data]

OBJECTIVE

Depersonalization is a fascinating clinical phenomenon referring to a self-consciousness disorder, characterized by emotional detachment from one's own feelings, thoughts, or actions. This article intends to summarize the current literature in this area.

METHOD

Using the Medline data base, we reviewed literature addressing the clinical, etiology, nosology, physiopathology, and treatment of depersonalization.

CONCLUSIONS

Derealization means that perception of the world and of external reality are altered. These 2 phenomena are often associated. They are not specific to any psychiatric entity and are reported in many different psychiatric syndromes. Many factors, including use of different substances, are involved in their onset. The physiopathology is still little known. However, some conceptual models suggest partial amygdala inhibition combined with activation of other amygdaloid structures. A serotoninergic functioning impairment is indicated in different pharmacologic studies. Different psychotropic drugs, especially serotoninergic antidepressants, have been proposed for pharmacotherapy; however, there are no conclusive randomized studies, and the contribution of psychotherapy in treating these patients is still questioned.

Die Erfassung des Depersonalisations- Derealisationssyndroms mit dem Fragebogen zu Dissoziativen Symptoment

OBJECTIVES

The goal of this study is to investigate the applicability of the German adaptation of the Dissociative Experiences Scale, the "Fragebogen zu dissoziativen Symptomen (FDS)", for research on depersonalization (DP) and derealization (DR), and to elucidate the phenomenology of DP / DR.

METHODS

101 consecutively recruited inpatients were diagnosed with the German version of the Structured Clinical Interview for DSM-IV Dissociative Disorders for depersonalization/derealization. Furthermore, the FDS and the SCL-90-R were administered.

RESULTS

47 of 101 Patients were diagnosed with pathological DP / DR. The mean score of the DES scale of the FDS was 32.00 +/- 15.52. A cut-off score of 17.5 for the DES scale of the FDS yielded a 83.0 % sensitivity and 77.8 % specificity. Depressive disorders, anxiety disorders and trauma-associated disorders were the most common comorbidity.

CONCLUSIONS

The findings are comparable to the Anglo-American samples. The FDS was found to be quite effective for screening of DP / DR. The three-factor solution of the FDS was not well supported in this sample.

Symptom profiles of natural and laboratory panic attacks

BACKGROUND

Little accurate information is available about the symptomatology of real-life panic attacks and about how well they are reproduced by an experimental model such as the 35% CO2 challenge.

METHOD

Real-life panic symptoms were assessed in a group of 67 panic disorder patients, using daily life monitoring. Panic symptoms elicited by a 35% CO2 challenge were assessed in 61 panic disorder patients, and their frequency was compared with the real-life symptoms.

RESULTS

The most frequent real-life symptoms were palpitations, dizziness and trembling. The 35% CO2 challenge reproduced well the majority of real-life symptoms.

CONCLUSION

The findings suggest that the 35% CO2 challenge is a marker for spontaneous panic attacks, which are considered the core of panic disorder.

Depersonalisation disorder: a cognitive–behavioural conceptualisation

Depersonalisation (DP) and derealisation (DR) are subjective experiences of unreality in, respectively, one's sense of self and the outside world. These experiences occur on a continuum from transient episodes that are frequently reported in healthy individuals under certain situational conditions to a chronic psychiatric disorder that causes considerable distress (depersonalisation disorder, DPD). Despite the relatively high rates of reporting these symptoms, little research has been conducted into psychological treatments for this disorder. We suggest that there is compelling evidence to link DPD with the anxiety disorders, particularly panic. This paper proposes that it is the catastrophic appraisal of the normally transient symptoms of DP/DR that results in the development of a chronic disorder. We suggest that if DP/DR symptoms are misinterpreted as indicative of severe mental illness or brain dysfunction, a vicious cycle of increasing anxiety and consequently increased DP/DR symptoms will result. Moreover, cognitive and behavioural responses to symptoms such as specific avoidances, 'safety behaviours' and cognitive biases serve to maintain the disorder by increasing awareness of the symptoms, heightening the perceived threat and preventing disconfirmation of the catastrophic misinterpretations. A coherent model facilitates the development of potentially effective cognitive and behavioural interventions.

A study of the phenomenology of panic attacks in patients from India

We studied the symptom structure of panic attacks in 94 patients attending an outpatient psychiatric clinic. Autonomic symptoms of anxiety were reported by the majority of the panic patients. As compared with studies from the West, certain cognitive symptoms, such as fear of loss of control and depersonalization, and vestibular symptoms were endorsed by fewer panic patients. The majority of our panic patients tended to seek help initially from physicians and medical specialists. The majority of the patients also did not experience some DSM-IV symptoms as part of their panic attacks. Comorbid psychiatric conditions influenced the symptom structure of panic attacks. A higher number of agoraphobics as compared with patients with uncomplicated panic disorders had the symptoms of fear of loss of control and fainting. Our findings support the notion that the experience of panic attacks is variable and differs across cultures.

Instrument to assess depersonalization-derealization in panic disorder

There is a long history of scholarly interest on depersonalization-derealization (DD) and its role in clinical anxiety, but there is a paucity of appropriate assessment instruments available. Our objective was to develop and evaluate a self-report measure of DD for use with clinically anxious patients. Panic disorder patients (n=169) were surveyed about DD experiences and provided data on a new item pool for psychometric development. DD episodes were common and a 28-item Depersonalization-Derealization Inventory was found to possess good reliability and validity. DD appears to be prevalent and clinically relevant in panic disorder. Continued study of DD is warranted and may be facilitated by the availability of a suitable instrument with promising psychometric properties. A 12-item version of the instrument may be appropriate as a brief screen.

Primary and secondary depersonalisation disorder: a psychometric study

INTRODUCTION

Depersonalisation may be part of a symptom-complex, a primary or a secondary disorder. Optimal methods of measurement and diagnosis have not been established.

METHODS

We assessed 42 patients with primary or secondary depersonalisation, plus psychiatric and non-psychiatric controls using a variety of self-report questionnaire scales including the Beck depression and anxiety Inventories, and one developed by the authors (the Fewtrell Depersonalisation Scale (FDS)). The correlations between the scales and measures of anxiety and depression were calculated, as were sensitivity and specificity against an operational case definition.

RESULTS

All the scales were highly correlated. All could distinguish depersonalisation cases from the rest but none could distinguish between primary and secondary depersonalisation disorder. Anxiety and especially depression were correlated with depersonalisation symptoms. The FDS had high sensitivity (85.7%) and specificity (92.3%) which compared favourably with other instruments. Patients with both derealisation and depersonalisation scored the highest on the FDS.

DISCUSSION

Depersonalisation disorder comprises a measurable cluster of symptoms which may be quantified with the help of self-report scales. Primary and secondary forms overlap, with depressed mood a frequent feature.

Depersonalization in panic disorder: a clinical study

Panic disorder (PD) has been hypothesized to be a heterogeneous entity, with distinct clinical subgroups. The presence of depersonalization during panic attacks may distinguish a specific subgroup of PD. We sought to analyze the differential features of a subgroup of PD patients with depersonalization. A total of 274 patients with PD were assessed and divided into 2 groups according to the presence or absence of depersonalization. The Structured Clinical Interview for DSM-III-R (SCID-UP-R) was used to assess PD and comorbid disorders. The clinical scales administered included the Hamilton Anxiety and Depression Rating Scale (HARS and HDRS), the Marks and Mathews Fears and Phobia Scale, Panic-Associated Symptom Scale (PASS), and a panic attack symptoms inventory. A total of 66 patients (24.1%) exhibited depersonalization during the attacks. Patients with depersonalization appeared to be younger and had an earlier age at onset. PD was more severe in the depersonalization group (greater number of attacks, worse level of functioning, and higher scores on most self-rating scales). Also, depersonalization patients showed more comorbidity with specific phobia. Our results support the view that PD with depersonalization may be considered a distinct and more severe subcategory of PD.

Differential clinical features of early-onset panic disorder

BACKGROUND

Although panic disorder (PD) begins typically in adulthood, an earlier onset is not uncommon. Recent studies on early-onset PD indicate that this subgroup of patients may display distinct clinical characteristics.

OBJECTIVE

To compare a subgroup of early-onset PD patients with the rest of the sample.

METHOD

A consecutive series of 442 patients with PD were included. Family histories were investigated, and clinical assessment employed the following instruments: Hamilton's scales, Global Functioning Scale, Marks-Mathews' Fears and Phobia Scale, and Panic-Associated Symptom Scale. The age threshold for 'early-onset' was considered at 18 years.

RESULTS

A total of 45 patients (10.2%) exhibited early-onset PD, with a mean age at onset of 14.6. They were younger and had a longer duration of illness than later-onset patients. No differences were found in severity of panic symptoms, anxiety or depressive symptoms, and social functioning. They had more comorbidity with simple phobia, social phobia, and substance dependence. Rates of PD among first-degree relatives were higher in the early-onset group.

CONCLUSION

Early-onset PD patients displayed a greater familial loading, but clinical severity of their panic-agoraphobia symptoms was not higher. Comorbidity was greater with phobic and substance-related disorders.

Regional cerebral blood flow and depersonalization after tetrahydrocannabinol administration

OBJECTIVE

The aim of this study was to examine the relationship between depersonalization induced by tetrahydrocannabinol (THC), and regional brain activation.

METHOD

Cerebral blood flow (CBF) was measured by means of positron emission tomography (PET) in 59 normal right-handed volunteers before and following intravenous infusions of THC.

RESULTS

After THC, CBF showed a global increase which was more marked in the right hemisphere, frontal lobes and anterior cingulate.

CONCLUSION

Regression analyses showed positive correlations between the right frontal and anterior cingulate and depersonalization.

Semiology and subtyping of panic disorders

To date, the quantitative psychopathology of panic disorder (PD) has been less well studied than that of other psychiatric conditions such as schizophrenia or major depression. The aim of the present study was to assess the frequency and factorial grouping of symptoms in a naturalistic sample of PD patients. A total of 274 consecutive cases of PD who contacted an out-patient clinic in Barcelona, Spain were assessed by two experienced interviewers. The assessment instruments included the Structured Clinical Interview for DSM-III-R Upjohn version (SCID-UP-R) and an inventory of panic attack symptoms based on DSM-III-R. Of the patients who presented at the unit during the assessment period, 8.5% presented with PD. Palpitations, shortness of breath, fear of dying and dizziness were the most frequent and intense symptoms reported by the PD patients. Principal-component analysis revealed four factors which accounted for 57% of the variance, including 'cardiorespiratory' (26.1%) and 'vestibular' (15.1%) factors, and two additional factors with mixed symptoms. The frequency of presentation of symptoms was similar to that reported in other studies. However, some discrepancies were observed that may be attributed to transcultural differences as well as to terminological problems and the range of symptoms assessed. These factors may also explain some of the differences found in factor analysis groupings in previous studies. Our findings support the symptom subtyping of PD.

Dissociative symptoms in panic disorder

The present study examined the prevalence and correlates of dissociative symptoms in patients with panic disorder and patients with other nonpanic anxiety disorders. A total of 56 patients with anxiety disorders (13 with panic disorder alone, 16 with comorbid panic and other anxiety, and 27 with other anxiety disorders) were assessed with structured clinical interviews and a battery of questionnaires. Although 69% of patients with panic disorder experienced depersonalization or derealization during their panic attacks, panic disorder patients were no more likely to experience dissociative experiences as assessed by the Dissociative Experience Scale than patients with other anxiety disorders. In the entire sample, the prevalence of dissociative experiences was very low and well within nonpathological ranges. The correlates of dissociative symptoms were severity of depression, social anxiety, and personality disorders. The implications of these findings for conceptualizing the nature of dissociative symptoms within an anxiety population are discussed.

Intrapatient agreement on phenomenology of panic attacks

Panic disorder is common in primary care settings and such a physician is often a patient's initial contact with the health care system. Previous work concerning the homogeneity of panic phenomenology across patients is contradictory. The purpose of this pilot study was to assess the intrapatient homogeneity of panic attacks and to examine associations between measures of homogeneity and physicians' confidence in the diagnosis. Ten patients meeting DSM-III-R criteria for panic disorder completed a diary documenting the symptomatic phenomenology of five consecutive panic attacks. In addition, the physician rated his diagnostic confidence for each patient. Patterns of symptoms and their sequences during panic showed good agreement within patients as did patterns of abatement and of presence of a precipitating event. The physician's diagnostic confidence was inversely related to agreement on symptom severity and variance of duration of an attack. This study suggests intrapatient homogeneity on most measures.

Psychosensorial and related phenomena in panic disorder and in temporal lobe epilepsy

Since Cullen coined the term "neurosis" in the 18th century, medical investigators have searched the neural substrates of conditions we now classify as anxiety disorders. Harper and Roth in 1962 hypothesized that the temporal lobes might represent one such substrate for phobic-anxious patients with depersonalization-derealization (DD); the association between the presumed temporal lobe feature and phobic anxiety was so compelling that Roth (in 1959) described the condition as "phobic-anxiety-depersonalization" syndrome. Introduced into our current nosology as panic disorder-agoraphobia (PDA), this seemingly neuropsychiatric condition is nonetheless distinct from complex partial epilepsy (CPE), from which it is conventionally differentiated through clinical and anamnestic evaluation. Yet increasingly there are clinical-and laboratory-hints of certain overlap between manifestations of the two disorders, hitherto based largely on evaluation of psychosensorial phenomena in PDA or affective phenomena in CPE. We located only one systematic study that monitored 24-hour electroencephalogram (EEG) abnormalities in PDA. Finally, recent epidemiologic data suggest a significantly greater than chance association between PDA and a history of seizures. To further explore these intriguing links, the present study directly compared a group of 91 PDA outpatients with a group of 41 CPE outpatients with respect to DD and other psychosensorial symptoms. The broad similarities discovered between psychosensorial and related phenomena provide further support for the hypothesis that there may be a common neurophysiological substrate linking CPE phenomena with PDA.

Reduction in dissociation due to aging and cognitive deficit

Our objective was to investigate whether dissociative experiences occur less frequently in older psychiatric patients than in younger adult patients, and to examine the role of cognitive deficits in the frequency of dissociative events. Fifty-two outpatients 60 years and older were administered the Dissociative Experiences Scale (DES) and the Mini-Mental State Exam (MMSE). Their scores were compared with those of 50 outpatients 35 to 55 years old. Each group included patients sampled from the Mental Health Center (MHC) and University Medical Center clinics. Older patients showed significantly lower DES and MMSE median scores than younger patients. Cognitive deficit reflected by reduced MMSE scores also was associated with reduced DES scores for younger and older patients. Older patients with little or no cognitive deficit continued to show reduced DES scores. Decreases in dissociativity continue well beyond the fourth decade and do not rely on age-related cognitive deficit. Factors related to the aging process seem to mediate reductions in dissociativity independent of reductions mediated by cognitive deficit. The use of the DES for screening without adjusting for age and cognitive status is questioned.

The symptom structure of panic attacks

Panic attack symptomatology was investigated in 212 panic disorder patients (60 men, 152 women) using the Panic Attack Questionnaire, Feelings of helplessness and thoughts of escape had the highest mean severity ratings, but are not currently listed in the DSM-III-R. The DSM-III-R symptoms labeled choking or smothering sensations, paresthesias, nausea, and chest pain had low severity ratings. Evidence was obtained for a three-factor model of panic symptomatology consisting of dizziness-related symptoms, cardiorespiratory distress, and cognitive factors. These results provide only limited support for the current DSM-III-R symptom structure, and support the notion that panic disorder is a heterogeneous condition.

The experimental induction of depersonalization and derealization in panic disorder and nonanxious subjects

The present study evaluated the efficacy of three tasks in inducing depersonalization (DP) and derealization (DR) in three different groups: (a) panic disorder patients who report these symptoms while panicking (PD + DD; n = 10); (b) panic disorder patients never experiencing these symptoms during panic attacks (PD; n = 10); and (c) nonanxious controls (NC; n = 10). Clinical features of the PD+DD and PD Ss were compared as well. Relative to PD Ss, PD + DD Ss evidenced higher levels of depression, trait anxiety, more fear of panic, and had a briefer duration of their disorder. A substantial proportion of NC Ss reported past DP and DR experiences. DP and DR induction procedures were the following: staring at a dot on the wall, staring in a mirror, and silent repetition of one's name. Results indicated two tasks (mirror and dot) successfully elicited these sensations above baseline levels with DP reported more frequently and intensely than DR for all Ss. The PD + DD Ss evidenced greater baseline-to-task increases in DP and DR relative to the other two groups and exhibited a differential fear response, particularly on the dot task, with 30% of these Ss intentionally distracting themselves or terminating the induction.