342 CHAPTER 8
Psychological Factors: Cognitive Defi cits
Patients with depersonalization disorder have cognitive defi cits that range from
problems with short-term memory to impaired spatial reasoning, but the root cause
of these diffi culties appears to lie with attention: These patients cannot easily focus
and sustain their attention (Guralnik et al., 2000, 2007). This is consistent with
neuroimaging studies that reveal decreased activity in parts of the brain that register
input from the senses. However, it is not clear whether the attentional problems are
a cause or an effect of the disorder: On one hand, if a person is feeling disconnected
from the world, he or she would not pay normal attention to objects and events;
on the other hand, if a person had such attentional problems, this could contribute
to feeling disconnected from the world. Moreover, given that many patients with
depersonalization disorder also have depression or an anxiety disorder (Baker et al.,
2003), it is not clear whether the problems with attention are specifi cally related to
depersonalization disorder or arise from the comorbid disorder.Social Factors: Childhood Emotional Abuse
We noted earlier that stressful events (often social in nature) can trigger depersonal-
ization disorder. Moreover, a particular type of social stressor—severe and chronic
emotional abuse experienced during childhood—seems to play a particularly impor-
tant role in triggering depersonalization disorder (Simeon et al., 2001), although it is
not clear why such abuse might lead to depersonalization disorder only in some cases.
Once the disorder develops, factors such as negative mood, stress, the perception
of threatening social interactions, and new environments can exacerbate its symp-
toms (Simeon, Knuteska, et al., 2003). For instance, if Mr. E in Case 8.3 had a fi ght
with a friend, his depersonalization symptoms would probably become worse during
the fi ght.P SNP SNCASE 8.3 • FROM THE OUTSIDE:Depersonalization Disorder
[Mr. E] was a 29-year-old, single man, employed as a journalist, who reported a 12-year history
of depersonalization disorder. He described feeling detached from the world as though he was
living “inside a bubble” and found it diffi cult to concentrate since he felt as though his brain
had been “switched off.” His body no longer felt solid and he could not feel himself walking
on the ground. The world appeared two-dimensional and he reported his sense of direction
and spatial awareness to be impaired. He described himself as having lost his “sense of him-
self” and felt that he was acting on “auto-pilot.” He also reported symptoms of depression
and some symptoms of OCD, which took the form of counting and stepping on cracks in the
pavement, although he did not report the latter as a problem.
Prior to the onset of his [depersonalization disorder], he experienced transient
[depersonalization] symptoms when intoxicated with cannabis. At the age of 17, he started at
a new school and felt very anxious and experienced [depersonalization] symptoms when not
under the infl uence of cannabis. He described the fi rst time this happened as “terrifying”
since he felt he had “gone into another world.” He reported difficulty with breathing and
believed he may have a brain tumor or that his “brain was traumatized into a state of panic.”
From the age of 17 to 19, the episodes of [depersonalization] became more frequent until they
became constantly present. He reports the symptoms as “enormously restricting” his life in
that he felt frustrated since he has been “unable to express or enjoy myself.”
(Hunter et al., 2003, Appendix A, pp. 1462–1463)FEEDBACK LOOPS IN ACTION: Depersonalization Disorder
One hypothesis for explaining depersonalization disorder is as follows: First, a
signifi cant stressor (often a social factor) elicits neurological events (largely in the
frontal lobes) that suppress the normal emotional responses (Hunter et al., 2003;
Sierra & Berrios, 1998; Simeon, Knutelska, et al., 2003). Following this, the discon-
nection between the intensity of the perceived stress and the lack of arousal may
lead these patients to feel “unreal,” which they may then attribute (a psychological
factor) to being mentally ill (Baker et al., 2007; Hunter et al., 2003). And, in turn,
the incorrect and catastrophic attributions that the patients make about their symp-
toms can lead to further anxiety (as occurs with panic disorder). The attributionsP SN