Mauricio Sierra. Depersonalisation Cambridge (UK): Cambridge University Press, 2009.
Depersonalisation is headlined in this book as a ‘neglected syndrome’ and we are offered a ‘new look’ at it. Well, yes it is a relatively neglected area in psychiatry. And yes, this book largely succeeds in delivering on its promise of a ‘new look’, in as far as there is truly ‘new’ material to look at!
But there is also a lot of historical material here, thoroughly reviewed and competently compiled, if a little dense at times. The book begins, indeed, with a ‘history’ of the concept, tracing its evolution and the changing views of it, from Griesinger and Esquirol, in the mid-19th century; to Pick and Janet in the early 20th; Dugas [quoting Amiel's famous (self) description of the phenomena], Schilder and L’hermitte and of course Jaspers; and Mayer-Gross and Roth taking us into the 1950s. Following the citations, it seemed much of the history was quiescent thereafter, until Diagnostic Statistical Manual (DSM) started to grapple with how to classify depersonalistaion in its third edition in 1980. And that nosological debate has continued, centering largely on whether it should be considered a dissociative disorder. Much of this debate is made more complex and difficult through different and shifting definitions of these terms, again a matter that still needs resolution.
The book then addresses the symptoms of depersonalisation, illustrated by useful descriptions from the literature. The reading of this chapter can be enhanced by reference to the Appendix, which presents the Cambridge Depersonalisation Scale, whose 29 items give a good sense of the symptoms and suggests how one might enquire of these, from patients. A chapter that is linked to this, but placed later in the book, is the cultural context, looking for example at collectivist and individualist cultural influences on how ‘scary’ the experience of depersonalisation might seem. This is important as it is highly likely that many people who experience depersonalisation simply accept it and are not sufficiently distressed by it to seek help. I would have thought this should be emphasised in informing treatment approaches.
Chapter 3 is a concerted stab at what one might consider ‘normal’ and ‘abnormal’ depersonalisation, considering four dimensions, viz.: frequency and duration of episodes, subjective intensity and number of symptoms. I am always sympathetic to dimensional approaches to psychiatric phenomena, and believe this approach has utility in terms of depersonalisation in particular, though of course it does not lend itself to the categorical nosological view so beloved of the authors of DSM. A number of rating scales for depersonalisation are also reviewed, with prominence given to the Cambridge Scale, reproduced in full in the Appendix.
‘Drug-induced’ depersonalisation disorder, psychiatric comorbidity in depersonalisation and depersonalisation in neurology are the subjects of the ensuing three chapters. The theme (very simplistically) is that the phenomena can be seen in junction with or consequent upon a number of ‘stressors’, including a wide range of psychiatric disorders, and some noted neurological ones, including migraine, epilepsy and vestibular disease. These understandings fit well with the dimension of vulnerability model, but also suggest some mechanisms whereby the phenomena are produced by the brain. This latter observation is looked at in some detail (and introducing some truly ‘new’ material) in an overview of the neurobiology of depersonalisation (the penultimate chapter of the book). Here, autonomic response (e.g. on exposure to unpleasant pictures) and functional neuroimaging (including some interesting pre- and post-treatment studies) are presented.
Treatment is covered in two chapters, predictably one being pharmacological and one psychological. Here, the paucity of information in the literature is underscored, with little by way of compelling data for any specific therapeutic approach. So, serotonin and glutamate get a mention. The most tantalising finding is that a combination of a serotonergic antidepressant and lamotrigine seems to have benefit over and above that attributable to either agent separately. A very small literature looks at the opioid system, with some patients showing a good response to naltrexone. These findings require confirmation in properly conducted, suitably sized, randomised controlled trials. Psychological techniques covered include abreaction (a few isolated reports of benefit), psychodynamic psychotherapy (case reports of benefit in selected patients) and cognitive behavioural therapy (an open trial of 21 patients showing benefit). More work, indeed, to be done!
The final chapter attempts an integration, with sections on ‘anterior insula and emotional feelings', ‘posterior insula and embodiment feelings' and ‘corticolimbic disconnection syndromes and depersonalisation’, leading to ‘a neurobiological model of depersonalisation’. So, it is a very biologically driven chapter, inevitable I guess, in the current era of biologically dominant research. I trust readers of this book will not read just the final chapter, but seek to gain a deeper understanding of this fascinating topic by, at the very least, a detailed review of the historical and dimensional chapters.
