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Depersonalization: Physiological or pathological in adolescents?
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ScienceDirect Comprehensive Psychiatry xx (2015) xxx – xxx www.elsevier.com/locate/comppsych
Depersonalization: Physiological or pathological in adolescents? Francesca Fagioli a, b,⁎, Alice Dell'Erba c , Vanina Migliorini d , Giovanni Stanghellini e, f a
Adolescents Mental Health Department, ASL Roma E, Rome, Italy b Department of Psychiatry, La Sapienza University, Rome, Italy c Mental Health Department, ASL Viterbo, Viterbo, Italy d Mental Health Department, ASL Roma D, Rome, Italy e G. d'Annunzio' University, Chieti, Italy f D. Portales' University, Santiago, Chile
Abstract Backgorund: This study analyzed the presence of DP symptoms in a sample of both psychiatric patients and normal subjects, addressing the issue of DP symptoms in adolescence. Methods: A total of 267 subjects (149 patients and 118 healthy controls) aged between 14 and 65 years, were assessed by means of CDS, the SCID-I and the K-SADS. The sample was then divided into two subsamples with a cut-off age of 21 years. Results: As expected CDS score was significantly higher in the patient group compared to the healthy control group. As for the age issue, among patients no statistical difference was found comparing subjects over and under 21 years, whereas in the sample of healthy controls, subjects under 21 years reported CDS scores significantly higher. Conclusions: While in adults DP symptoms are frequently associated with mental disorders, in adolescents they could be considered as a quasi-physiological phenomenon. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Depersonalization (DP), for long a complex and obscure subject of clinical psychiatry, has become a recurrent topic of psychopathology in the last 10 years [9,21,26,15,13,29,3,8,10,12,19]. It is characterized by persistent or recurrent episodes of detachment from one's self: individuals may feel like an automaton or they may have a sensation of estrangement from their own mental processes, emotions or body shape [2]. Often accompanied by derealization (DR), a threatening sense of unreality from the environment, DP can assume various nuanced forms in clinical practice. It occurs on a continuum ranging from transient episodes in healthy people to a significant complex
Abbreviations: DP, depersonalization; CDS, Cambridge Depersonalization Scale; SCID-I, Structured Clinical Interview for DSM-IV axis I Disorders; K-SADS, Schedule of Affective Disorders and Schizophrenia for School-Age Children–Revised for DSM-IV. ⁎ Corresponding author at: U.O.C. Tutela Adolescenza, Via Plinio 31, 00198 Rome, Italy. Tel.: +39 3476489771; fax: +39 668354019. E-mail address: [email protected] (F. Fagioli). http://dx.doi.org/10.1016/j.comppsych.2015.02.011 0010-440X/© 2015 Elsevier Inc. All rights reserved.
of symptoms—in other psychiatric illnesses, or as a primary mental disorder [11,26]. Current epidemiological data show a prevalence of clinically significant DP/DR of approximately 1%–2% in the general population, similar to the prevalence of common mental disorders such as bipolar disorder and obsessive–compulsive disorder [14]. The first systematic epidemiological review shows that the transient symptoms of DP in the general population have a lifetime prevalence ranging between 26% and 74% [9]. To date DP has mostly been investigated in adults but it is emerging as a transient or recurrent experience in youth where it appears to be a puzzling and perhaps consequential phenomenon about which little is still known. The evidence that the onset of DP is in adolescence [25,28] leads us to focus on this period when subjects complain about many physical and mental changes. It should be noted that the majority of these complaints are stated in terms of experiences of alienation or unreality that are usually prevalent in DP. In this paper we explore DP in adolescence. Its aim is to compare DP symptoms in adolescents with those in adults, first in patients suffering from mental disorders and then in healthy individuals.
2
F. Fagioli et al. / Comprehensive Psychiatry xx (2015) xxx–xxx
2. Materials and methods 2.1. Participants A total of 267 subjects (149 patients and 118 healthy subjects) were recruited consecutively (from June 2010 to March 2013) in Rome, in the ASL RM E catchment area. Inclusion criteria for the 118 healthy subjects were: aged between 14 and 65 years, comprehension of Italian language, and IQ N 70. Exclusion criteria were: presence of any psychiatric disease, DP symptoms due to a medical condition or to a neurological disorder, drug abuse, and psychopharmacological treatments. The subjects were recruited from 3 high schools and from 3 general practitioners' offices. Inclusion criteria for the 149 patients were: aged between 14 and 65 years, comprehension of Italian language, and IQ N 70. Exclusion criteria were: DP symptoms due to a medical condition, or to a neurological disorder, and drug abuse. The subjects were in and outpatients recruited from the ASL RM E Psychiatric Department. Patients and healthy controls were matched for demographic characteristics. All subjects, or legal representatives if underage, read and signed the informed consent form. 2.2. Measures Subjects over 18 years were administered the Structured Clinical Interview for DSM IV (SCID I), while those aged under 18 were administered the Schedule of Affective Disorders and Schizophrenia for School-Age Children–Revised for DSM-IV (K-SADS). CDS was used to evaluate the presence of DP symptoms. The Structured Clinical Interview for DSM IV (SCID-I; [30,31]) is a semi-structured interview used to assess current and lifetime psychiatric disorders and. Current disorders are defined as those present during the last month, whereas lifetime disorders are those that an individual has had at any other point (i.e., past or present) in his or her lifetime. The SCID consists of structured questions that the interviewer uses to determine whether diagnostic criteria have been met. The reliability and validity of the SCID-I have been well documented, with inter-rater reliability agreement (kappa) ranging from .70 to 1.00 (e.g., Refs, [7,20,24,33,35]). The Schedule of Affective Disorders and Schizophrenia for School-Age Children–Revised for DSM-IV (K-SADS [18]). The K-SADS is a semi-structured interview used by trained clinical interviewers. It assesses the presence of previous and current psychiatric disorders based on information provided by both the patient and the patient's guardian. Diagnoses based on the K-SADS have shown excellent reliability and validity among clinical samples [18]. The Cambridge Depersonalization Scale, Italian version (CDS IV) [16]. The scale is a self-administered questionnaire composed of 29 items. Each item is assessed on two Likert scales, one for frequency (0 = never to 4 = all the time) and the other for duration (1 = few seconds to 6 = more than a week) of experience (range 0–10). The global score of the scale is obtained from the algebraic sum of the score of frequency and
duration of each item (range 0–290), and represents the final measurement of intensity. The CDS IV showed high internal consistency (Cronbach's alpha of 0.90) and a good internal coherence (N0.70) with good specificity (SP = 0.92) and sensitivity (S = 0.90). This tool has been found to effectively discriminate depersonalization disorder from other conditions, either organic (e.g., temporal lobe epilepsy) or psychiatric (e.g., anxiety disorders) [27]. In analyzing mean scores, we considered the total score and the score of 2 of the 4 factors derived from a factorial analysis we previously performed [6]: Unreality of Self (US) and Anomalous Body Experiences (ABE). The former, Unreality of Self, comprises five items (10, 11, 23, 24, 26) which assess an individual's experiences of detachment from actions and thoughts of an individual. It adopts the classical definition and description of DP, but mostly deals with cognitive experience of DP. The latter, Anomalous Bodily Experiences (items 27, 23, 20, 3, 22, 12), mostly refers to bodily experiences and includes the experience of the distortion of body perception. 2.3. Statistical analysis The one way ANOVA was used to compare the CDS mean scores. Data were analyzed with the Statistical Package for the Social Sciences (SPSS) version 17.0.1 (2008) [32]. 3. Results 3.1. Sample A total of 267 subjects were recruited: 119 males and 148 females, with a mean age of 29.86 ± 32.27. The sample was then divided into two sub-samples with a cut-off age of 21 years; in the clinical sample, 54 subjects were found to be affected by depression, 29 by anxiety, and 66 by psychosis (Table 1). 3.2. Healthy controls Fifty-six males and 62 females, with a mean age of 30.25, comprised the healthy control group; 11.7% of the sample Table 1 Sample: demographics, diagnosis and CDS scores.
Males Females Mean age CDS TOT ABE US Healthy controls Patients Depression Anxiety Psychosis Total
b21aa
N21 aa
Total
52 56 17.61 ± 1.07 50.78 ± 25.04 11.31 ± 5.13 9.37 ± 3.12 53 55 15 10 30 108
67 92 42.12 ± 2.37 42.69 ± 15.54 10.50 ± 4.34 8.50 ± 4.21 65 94 39 19 36 159
119 148 29.86 ± 14.78 45.97 ± 20.44 10.83 ± 7.13 8.85 ± 2.32 118 149 54 29 66 267
CDS TOT = Cambridge Depersonalization Scale, total score; ABE = Anomalous Body Experiences subscale; US = Unreality of Self subscale.
F. Fagioli et al. / Comprehensive Psychiatry xx (2015) xxx–xxx Table 2 Healthy controls: demographics, diagnosis and ANOVA for age groups.
Males Females Mean age CDS TOT ABE US Total
b21aa
N21aa
Total
31 22 17.10 ± 2.3 34.62 ± 23.90⁎ (F = 38.4) 5.90 ± 6.12⁎⁎(F = 14.99) 6.28 ± 5.51⁎ (F = 29.52) 53
25 40 43.40 ± 3.5 12.70 ± 13.78 2.30 ± 3.90 2.01 ± 2.82 65
56 62 30.25 ± 4.3 22.55 ± 21.85 3.92 ± 5.31 3.93 ± 4.73 118
CDS TOT = Cambridge Depersonalization Scale, total score; ABE = Anomalous Body Experiences subscale; US = Unreality of Self subscale; F = F-ratio. ⁎ P = 0.000. ⁎⁎ P b 0.001.
reached a score greater than the cut-off of 59. CDS mean scores were significantly higher in the subgroup of subjects aged b21 years (Table 2). 3.3. Patients Sixty-two males and 87 females, with a mean age of 32.39 years, comprised the patient group. Fifty-one percent of the sample reached a score greater than the cut-off of 59. There was no significant difference in CDS mean scores between patients under and over 21 years (Table 3). Comparing CDS mean scores of the 149 patients and of the 118 healthy subjects, a statistical difference was found (Table 4). 4. Discussion In the healthy sample, young subjects showed significantly more DP symptoms compared to older subjects. These data partially confirm literature where it seems that the occasional experience of unreality is rather common among adolescents and that these occasional experiences of DP are not necessarily experienced as disturbing [5]. In 1966 Sedman [23], in contrast to Robert's [22] and Dixon's studies [4], revealed that in college students there was a high incidence of brief depersonalization experiences, mostly in younger individuals. It is also estimated that DP onset occurs Table 3 Patients: demographics, diagnosis and ANOVA for age groups.
Males Females Age CDS TOT ABE US Depression Anxiety Psychosis Ttotal
b21aa
N21aa
Total
21 34 18.05 66.36 16.52 12.36 15 10 30 55
41 53 40.78 63.43 16.18 12.98 39 19 36 94
62 87 29.41 64.51 16.30 12.75 54 29 66 149
± ± ± ±
1.82 46.02 (F = 0.15) 14.07 (F = 0.02) 9.89 (F = 0.14)
± ± ± ±
11.94 42.51 15.33 10.01
± ± ± ±
14.55 43.71 14.83 9.94
CDS TOT = Cambridge Depersonalization Scale, total score; ABE = Anomalous Body Experiences subscale; US = Unreality of Self subscale; F = F-ratio.
3
Table 4 ANOVA for healthy controls vs patients.
CDS TOT ABE US
Healthy controls
Patients
22.55 ± 21.85 3.92 ± 5.31 3.93 ± 4.73
64.51 ± 43.71⁎ (F = 90.74) 16.30 ± 14.83⁎ (F = 74.61) 12.75 ± 9.94⁎ (F = 78.79)
CDS TOT = Cambridge Depersonalization Scale, total score; ABE = Anomalous Body Experiences subscale; US = Unreality of Self subscale; F = F-ratio. ⁎ P = 0.000.
around 15–16 years of age [25,28]. In young subjects DP is very common and it seems that DP decreases with age. Some studies reported a high 1-year prevalence of DP/DR experiences in the general population (19.1%) and our study showed a decrease with age (to 31% age 18–22 to 5.70% age 76–90) [1]. In 2004, Moyano et al. [17] found that healthy adolescents (12–17 years) presented more DP symptoms compared to peers affected by psychiatric disorders. The same conclusions emerged in a work by Yoshizumi [36], showing a peak of incidence of DP experiences between 11 and 12 years of age in the general population. Since DP appears to be very common in adolescence, some studies have shown that it can affect the phenomenology of depression if we compare the two age groups. For example body dissatisfaction seems to be less characteristic of depression (in terms of self-deprecation) in adolescence, simply because a feeling of ugliness and estrangement of the body is a consequence of pubertal changes, particularly for girls [34]. We also found that in young subjects, clinical ones as compared to healthy ones show significantly higher scores of DP phenomena as it could be expected. Also, in our clinical sample no differences were found between young and older subjects: DP symptoms were shown to be equally distributed. As previously noticed, in assessing DP symptoms, besides CDS total score, we also considered two of four factors extracted by a previous factorial analysis [6]: Unreality of Self and Anomalous Body Experiences. Recent empirical and psychopatological works show that certain cognitive symptoms and anomalous body experiences are psychopatological features which could be of substantial importance for the issue of early identification of subjects at risk of transition to major psychiatric disorders [37]. We must admit that such feelings which include cenesthesias, body abnormal feelings, physical discomfort, and body sensations, and are very difficult for the patient to describe and for the clinician to recognize, having a clear color of “unusual” and “strangeness”, could be therefore typical in adolescence. It is very important to note that CDS is not designed to identify more subtle nuances that may help discriminate qualitatively different forms of DP, as for instance DP phenomena that are specific to schizophrenic prodromes, or full-blown schizophrenia, or other anomalies of self- and body-experience typical of bipolar disorder. We can hypothesize that ad hoc scales (e.g., BSABS, EASE, ABPq) may have identified a phenomenological difference between healthy and clinical subjects.
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F. Fagioli et al. / Comprehensive Psychiatry xx (2015) xxx–xxx
5. Conclusions Although DP phenomena are more common in subjects with a psychiatric diagnosis of anxiety, depression or psychotic disorder, our study shows that these changes in one's bodily and self experience are also very common in healthy adolescents. In adolescents without a psychiatric diagnosis, DP experiences are likely to be present although in a transient way. Also, their intensity is likely to decrease with age and as one's sense of familiarity with one's body, self and environment is restored. Our results confirm an established view about adolescence, which can be seen as a disturbing period that may be accompanied by uncanny feelings of depersonalization. During adolescence the distress related to one's own bodily feelings and appearance starts to take place. One's image in the mirror is displeasing and every little defect may cause a sense of insecurity. Adolescents may feel their own body almost as something unfamiliar, likely to be judged by others. We may conclude that in adolescence DP is a quasi-physiological, although disturbing phenomenon that occurs rather frequently and in general has a good prognosis. However, since DP phenomena, with a good prognosis in adolescence, are hardly distinguishable at face value from other DP phenomena that may precede severe mental disorders, clinicians should not underestimate the risk of a transition of a subgroup of these ‘healthy’ subjects into some form of psychosis. It is advisable to assess adolescents showing persistent DP phenomena, or at-risk subjects, or subjects with DP and a psychiatric diagnosis, with ad hoc tools designed to evaluate anomalies of self and bodily experience that are specific for psychotic disorders, and especially schizophrenia.
References [1] Aderibigbe YA, Bloch RM, Walker WR. Prevalence of depersonalization and derealization experiences in a rural population. Soc Psychiatry Psychiatr Epidemiol 2001;36:63-9. [2] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th edn (DSM-V). Arlington, VA: American Psychiatric Publishing; 2014. [3] Baker D, Hunter E, Lawrence E, Medford N, Patel MX, Senior C, et al. Depersonalization disorder: clinical features of 204 cases. Br J Psychiatry 2003;182:428-33. [4] Dixon JC. Depersonalization phenomena in a sample population of college students. Br J Psychiatry 1963;109:371-5. [5] Elliott GC, Rosenberg M, Wagner M. Transient depersonalization in youth. Soc Psychol Q 1984;47:115-29. [6] Fagioli F, Telesforo L, Dell'Erba A, Consolazione M, Migliorini V, Patanè M, et al. Depersonalization: an exploratory factor analysis of the Italian version of the Cambridge Depersonalization Scale. Compr Psychiatry 2014 [in press]. [7] First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-CV). Washington DC: American Psychiatric Press, Inc; 1996. [8] Graux J, Lemoine M, El Hage W, Camus V. From depersonalization to hallucination. Psychopathology 2012;45:42-52.
[9] Hunter ECM, Sierra M, David AS. The epidemiology of depersonalization and derealization. A systematic review. Soc Psychiatry Psychiatr Epidemiol 2004;39:9-18. [10] Lambert MV, Sierra M, Phillips ML, David AS. The spectrum of organic depersonalization: a review plus four new cases. J Neuropsychiatry Clin Neurosci 2002;14:141-54. [11] Lambert MV, Senior C, Fewtrell WD, Phillips ML, David AS. Primary and secondary depersonalization disorder: a psychometric study. J Affect Disord 2001;63:249-56. [12] Lee WE, Kwok CH, Hunter EC, Richards M, David AS. Prevalence and childhood antecedents of depersonalization syndrome in a UK birth cohort. Soc Psychiatry Psychiatr Epidemiol 2012;47:253-61. [13] Maggini C, Raballo A, Salvatore P. Depersonalization and basic symptoms in schizophrenia. Psychopathology 2002;35:17-24. [14] Michal M, Wiltink J, Subic-Wrana C, Zwerenz R, Tuin I, Lichy M, et al. Prevalence, correlates and predictors of depersonalization experiences in the German general population. J Nerv Ment Dis 2009;197:499-506. [15] Michal M, Wiltink J, Till Y, Wild PS, Blettner M, Beutel ME. Distinctiveness and overlap of depersonalization with anxiety and depression in a community sample: results from Gutemberg Heart Study. Psychiatry Res 2011;188:264-8. [16] Migliorini V, Dell'Erba A, Fagioli F, Sierra M, Mosticoni S, Telesforo L, et al. Italian (cross cultural) adaptation and validation of the Cambridge Depersonalization Scale (CDS). Epidemiol Psichiatr Sci 2012;21:221-6. [17] Moyano O, Thiébaut E, Claudon P. Comparaison des experiences dissociatives à l'adolescence entre un groupe de collégiens et un groupe clinique. Ann Med Psychol 2004;162:533-40. [18] Kaufman J, Birmaher B, Brent D, Rao U, Flynn C, Moreci P, et al. Schedule for affective disorders and schizophrenia for schoolage children—present and life-time version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 1997;36:980-8. [19] Sass L, Pienkos E, Nelson B, Medford N. Anomalous self-experience in depersonalization and schizophrenia: a comparative investigation. Conscious Cogn 2013;22:430-41. [20] Skre I, Onstad S, Torgersen S, Kringlen E. High interrater reliability for the Structured Clinical Interview for DSM-III-R Axis I (SCID-I). Acta Psychiatr Scand 1991;84:167-73. [21] Parnas J, Handset P. Phenomenology of self-experience in early schizophrenia. Compr Psychiatry 2003;44:121-34. [22] Robert WW. Normal and abnormal depersonalization. J Ment Sci 1960;106:478-93. [23] Sedman G. Depersonalization in a group of normal subject. Br J Psychiatry 1966;112:907-12. [24] Segal DL, Hersen M, Van Hasselt VB. Reliability of the Structured Clinical Interview for DSM-III-R: an evaluative review (review). Compr Psychiatry 1994;35:316-27. [25] Shimizu M, Sakamoto S. Depersonalization in early adolescence. Jpn J Psychiatry Neurol 1986;40:603-8. [26] Sierra M. La depersonalizzazione una nuova prospettiva. 2009. Roma: Astrolabio; 2011. [27] Sierra M, Berrios GE. The Cambridge Depersonalization Scale: a new instrument for the measurement of depersonalization. Psychiatry Res 2000;93:153-64. [28] Simeon D, Knutelska M, Nelson D, Guralnik O. Feeling unreal: a depersonalization disorder update of 117 cases. J Clin Psychiatry 2003;64:990-7. [29] Simeon D, Hamilton H. Depersonalization disorder and schizotypal personality disorder. In: Moskowitz A, Schäfer I, & Dorahy MJ, editors. Psychosis, trauma and dissociation: emerging perspectives on severe psychopathology. New York: Wiley-Blackwell; 2008. p. 209-20. [cap. 15]. [30] Spitzer RL, Williams JB, Gibbon M, First MG. Structured Clinical Interview for DSM-III-R- Patient edition (SCID-P). New York: Biometrics Research Department, New York State Psychiatric Institute; 1990. [31] Spitzer RL, Williams JB, Gibbon M, First MG. The Structured Clinical Interview for DSM-III-R (SCID): I. History, rationale, and description. Arch Gen Psychiatry 1992;49:624-9.
F. Fagioli et al. / Comprehensive Psychiatry xx (2015) xxx–xxx [32] Statistical Package for the Social Sciences (SPSS). SPSS Statistics, Version 17.0.1. Chicago: SPSS Inc; 2008 [III]. [33] Strakowski SM, Wilson DR, Tohen M, Woods BT, Douglass AW, Stoll AL. Structural brain abnormalities in first-episode mania. Biol Psychiatry 1993;33:602-9. [34] Van Beek Y, Hessen DJ, Hutteman R, Verhulp EE, Van Leuven M. Age and gender differences in depression across adolescence: real or ‘bias'. J Child Psychol Psychiatry 2012;53:973-85.
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[35] Williams JBW, Gibbon M, First MB, Spitzer RL, Davis M, Borus J, et al. The Structured Clinical Interview for DSM-III-R (SCID) II. Multi-site test–retest reliability. Arch Gen Psychiatry 1992;49:630-6. [36] Yoshizumi T. The relationship between dissociation and aggression in adolescents with using P–F Study. Jpn J Pers 2010;19(1):62-4. [37] Fusar-Poli P, Yung AR, McGorry P, van Os J. Psychol Med 2010;19(1):62-4, http://dx.doi.org/10.1017/S0033291713000184 [Epub 2013 Feb 18. Review].
ScienceDirect Comprehensive Psychiatry xx (2015) xxx – xxx www.elsevier.com/locate/comppsych
Depersonalization: Physiological or pathological in adolescents? Francesca Fagioli a, b,⁎, Alice Dell'Erba c , Vanina Migliorini d , Giovanni Stanghellini e, f a
Adolescents Mental Health Department, ASL Roma E, Rome, Italy b Department of Psychiatry, La Sapienza University, Rome, Italy c Mental Health Department, ASL Viterbo, Viterbo, Italy d Mental Health Department, ASL Roma D, Rome, Italy e G. d'Annunzio' University, Chieti, Italy f D. Portales' University, Santiago, Chile
Abstract Backgorund: This study analyzed the presence of DP symptoms in a sample of both psychiatric patients and normal subjects, addressing the issue of DP symptoms in adolescence. Methods: A total of 267 subjects (149 patients and 118 healthy controls) aged between 14 and 65 years, were assessed by means of CDS, the SCID-I and the K-SADS. The sample was then divided into two subsamples with a cut-off age of 21 years. Results: As expected CDS score was significantly higher in the patient group compared to the healthy control group. As for the age issue, among patients no statistical difference was found comparing subjects over and under 21 years, whereas in the sample of healthy controls, subjects under 21 years reported CDS scores significantly higher. Conclusions: While in adults DP symptoms are frequently associated with mental disorders, in adolescents they could be considered as a quasi-physiological phenomenon. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Depersonalization (DP), for long a complex and obscure subject of clinical psychiatry, has become a recurrent topic of psychopathology in the last 10 years [9,21,26,15,13,29,3,8,10,12,19]. It is characterized by persistent or recurrent episodes of detachment from one's self: individuals may feel like an automaton or they may have a sensation of estrangement from their own mental processes, emotions or body shape [2]. Often accompanied by derealization (DR), a threatening sense of unreality from the environment, DP can assume various nuanced forms in clinical practice. It occurs on a continuum ranging from transient episodes in healthy people to a significant complex
Abbreviations: DP, depersonalization; CDS, Cambridge Depersonalization Scale; SCID-I, Structured Clinical Interview for DSM-IV axis I Disorders; K-SADS, Schedule of Affective Disorders and Schizophrenia for School-Age Children–Revised for DSM-IV. ⁎ Corresponding author at: U.O.C. Tutela Adolescenza, Via Plinio 31, 00198 Rome, Italy. Tel.: +39 3476489771; fax: +39 668354019. E-mail address: [email protected] (F. Fagioli). http://dx.doi.org/10.1016/j.comppsych.2015.02.011 0010-440X/© 2015 Elsevier Inc. All rights reserved.
of symptoms—in other psychiatric illnesses, or as a primary mental disorder [11,26]. Current epidemiological data show a prevalence of clinically significant DP/DR of approximately 1%–2% in the general population, similar to the prevalence of common mental disorders such as bipolar disorder and obsessive–compulsive disorder [14]. The first systematic epidemiological review shows that the transient symptoms of DP in the general population have a lifetime prevalence ranging between 26% and 74% [9]. To date DP has mostly been investigated in adults but it is emerging as a transient or recurrent experience in youth where it appears to be a puzzling and perhaps consequential phenomenon about which little is still known. The evidence that the onset of DP is in adolescence [25,28] leads us to focus on this period when subjects complain about many physical and mental changes. It should be noted that the majority of these complaints are stated in terms of experiences of alienation or unreality that are usually prevalent in DP. In this paper we explore DP in adolescence. Its aim is to compare DP symptoms in adolescents with those in adults, first in patients suffering from mental disorders and then in healthy individuals.
2
F. Fagioli et al. / Comprehensive Psychiatry xx (2015) xxx–xxx
2. Materials and methods 2.1. Participants A total of 267 subjects (149 patients and 118 healthy subjects) were recruited consecutively (from June 2010 to March 2013) in Rome, in the ASL RM E catchment area. Inclusion criteria for the 118 healthy subjects were: aged between 14 and 65 years, comprehension of Italian language, and IQ N 70. Exclusion criteria were: presence of any psychiatric disease, DP symptoms due to a medical condition or to a neurological disorder, drug abuse, and psychopharmacological treatments. The subjects were recruited from 3 high schools and from 3 general practitioners' offices. Inclusion criteria for the 149 patients were: aged between 14 and 65 years, comprehension of Italian language, and IQ N 70. Exclusion criteria were: DP symptoms due to a medical condition, or to a neurological disorder, and drug abuse. The subjects were in and outpatients recruited from the ASL RM E Psychiatric Department. Patients and healthy controls were matched for demographic characteristics. All subjects, or legal representatives if underage, read and signed the informed consent form. 2.2. Measures Subjects over 18 years were administered the Structured Clinical Interview for DSM IV (SCID I), while those aged under 18 were administered the Schedule of Affective Disorders and Schizophrenia for School-Age Children–Revised for DSM-IV (K-SADS). CDS was used to evaluate the presence of DP symptoms. The Structured Clinical Interview for DSM IV (SCID-I; [30,31]) is a semi-structured interview used to assess current and lifetime psychiatric disorders and. Current disorders are defined as those present during the last month, whereas lifetime disorders are those that an individual has had at any other point (i.e., past or present) in his or her lifetime. The SCID consists of structured questions that the interviewer uses to determine whether diagnostic criteria have been met. The reliability and validity of the SCID-I have been well documented, with inter-rater reliability agreement (kappa) ranging from .70 to 1.00 (e.g., Refs, [7,20,24,33,35]). The Schedule of Affective Disorders and Schizophrenia for School-Age Children–Revised for DSM-IV (K-SADS [18]). The K-SADS is a semi-structured interview used by trained clinical interviewers. It assesses the presence of previous and current psychiatric disorders based on information provided by both the patient and the patient's guardian. Diagnoses based on the K-SADS have shown excellent reliability and validity among clinical samples [18]. The Cambridge Depersonalization Scale, Italian version (CDS IV) [16]. The scale is a self-administered questionnaire composed of 29 items. Each item is assessed on two Likert scales, one for frequency (0 = never to 4 = all the time) and the other for duration (1 = few seconds to 6 = more than a week) of experience (range 0–10). The global score of the scale is obtained from the algebraic sum of the score of frequency and
duration of each item (range 0–290), and represents the final measurement of intensity. The CDS IV showed high internal consistency (Cronbach's alpha of 0.90) and a good internal coherence (N0.70) with good specificity (SP = 0.92) and sensitivity (S = 0.90). This tool has been found to effectively discriminate depersonalization disorder from other conditions, either organic (e.g., temporal lobe epilepsy) or psychiatric (e.g., anxiety disorders) [27]. In analyzing mean scores, we considered the total score and the score of 2 of the 4 factors derived from a factorial analysis we previously performed [6]: Unreality of Self (US) and Anomalous Body Experiences (ABE). The former, Unreality of Self, comprises five items (10, 11, 23, 24, 26) which assess an individual's experiences of detachment from actions and thoughts of an individual. It adopts the classical definition and description of DP, but mostly deals with cognitive experience of DP. The latter, Anomalous Bodily Experiences (items 27, 23, 20, 3, 22, 12), mostly refers to bodily experiences and includes the experience of the distortion of body perception. 2.3. Statistical analysis The one way ANOVA was used to compare the CDS mean scores. Data were analyzed with the Statistical Package for the Social Sciences (SPSS) version 17.0.1 (2008) [32]. 3. Results 3.1. Sample A total of 267 subjects were recruited: 119 males and 148 females, with a mean age of 29.86 ± 32.27. The sample was then divided into two sub-samples with a cut-off age of 21 years; in the clinical sample, 54 subjects were found to be affected by depression, 29 by anxiety, and 66 by psychosis (Table 1). 3.2. Healthy controls Fifty-six males and 62 females, with a mean age of 30.25, comprised the healthy control group; 11.7% of the sample Table 1 Sample: demographics, diagnosis and CDS scores.
Males Females Mean age CDS TOT ABE US Healthy controls Patients Depression Anxiety Psychosis Total
b21aa
N21 aa
Total
52 56 17.61 ± 1.07 50.78 ± 25.04 11.31 ± 5.13 9.37 ± 3.12 53 55 15 10 30 108
67 92 42.12 ± 2.37 42.69 ± 15.54 10.50 ± 4.34 8.50 ± 4.21 65 94 39 19 36 159
119 148 29.86 ± 14.78 45.97 ± 20.44 10.83 ± 7.13 8.85 ± 2.32 118 149 54 29 66 267
CDS TOT = Cambridge Depersonalization Scale, total score; ABE = Anomalous Body Experiences subscale; US = Unreality of Self subscale.
F. Fagioli et al. / Comprehensive Psychiatry xx (2015) xxx–xxx Table 2 Healthy controls: demographics, diagnosis and ANOVA for age groups.
Males Females Mean age CDS TOT ABE US Total
b21aa
N21aa
Total
31 22 17.10 ± 2.3 34.62 ± 23.90⁎ (F = 38.4) 5.90 ± 6.12⁎⁎(F = 14.99) 6.28 ± 5.51⁎ (F = 29.52) 53
25 40 43.40 ± 3.5 12.70 ± 13.78 2.30 ± 3.90 2.01 ± 2.82 65
56 62 30.25 ± 4.3 22.55 ± 21.85 3.92 ± 5.31 3.93 ± 4.73 118
CDS TOT = Cambridge Depersonalization Scale, total score; ABE = Anomalous Body Experiences subscale; US = Unreality of Self subscale; F = F-ratio. ⁎ P = 0.000. ⁎⁎ P b 0.001.
reached a score greater than the cut-off of 59. CDS mean scores were significantly higher in the subgroup of subjects aged b21 years (Table 2). 3.3. Patients Sixty-two males and 87 females, with a mean age of 32.39 years, comprised the patient group. Fifty-one percent of the sample reached a score greater than the cut-off of 59. There was no significant difference in CDS mean scores between patients under and over 21 years (Table 3). Comparing CDS mean scores of the 149 patients and of the 118 healthy subjects, a statistical difference was found (Table 4). 4. Discussion In the healthy sample, young subjects showed significantly more DP symptoms compared to older subjects. These data partially confirm literature where it seems that the occasional experience of unreality is rather common among adolescents and that these occasional experiences of DP are not necessarily experienced as disturbing [5]. In 1966 Sedman [23], in contrast to Robert's [22] and Dixon's studies [4], revealed that in college students there was a high incidence of brief depersonalization experiences, mostly in younger individuals. It is also estimated that DP onset occurs Table 3 Patients: demographics, diagnosis and ANOVA for age groups.
Males Females Age CDS TOT ABE US Depression Anxiety Psychosis Ttotal
b21aa
N21aa
Total
21 34 18.05 66.36 16.52 12.36 15 10 30 55
41 53 40.78 63.43 16.18 12.98 39 19 36 94
62 87 29.41 64.51 16.30 12.75 54 29 66 149
± ± ± ±
1.82 46.02 (F = 0.15) 14.07 (F = 0.02) 9.89 (F = 0.14)
± ± ± ±
11.94 42.51 15.33 10.01
± ± ± ±
14.55 43.71 14.83 9.94
CDS TOT = Cambridge Depersonalization Scale, total score; ABE = Anomalous Body Experiences subscale; US = Unreality of Self subscale; F = F-ratio.
3
Table 4 ANOVA for healthy controls vs patients.
CDS TOT ABE US
Healthy controls
Patients
22.55 ± 21.85 3.92 ± 5.31 3.93 ± 4.73
64.51 ± 43.71⁎ (F = 90.74) 16.30 ± 14.83⁎ (F = 74.61) 12.75 ± 9.94⁎ (F = 78.79)
CDS TOT = Cambridge Depersonalization Scale, total score; ABE = Anomalous Body Experiences subscale; US = Unreality of Self subscale; F = F-ratio. ⁎ P = 0.000.
around 15–16 years of age [25,28]. In young subjects DP is very common and it seems that DP decreases with age. Some studies reported a high 1-year prevalence of DP/DR experiences in the general population (19.1%) and our study showed a decrease with age (to 31% age 18–22 to 5.70% age 76–90) [1]. In 2004, Moyano et al. [17] found that healthy adolescents (12–17 years) presented more DP symptoms compared to peers affected by psychiatric disorders. The same conclusions emerged in a work by Yoshizumi [36], showing a peak of incidence of DP experiences between 11 and 12 years of age in the general population. Since DP appears to be very common in adolescence, some studies have shown that it can affect the phenomenology of depression if we compare the two age groups. For example body dissatisfaction seems to be less characteristic of depression (in terms of self-deprecation) in adolescence, simply because a feeling of ugliness and estrangement of the body is a consequence of pubertal changes, particularly for girls [34]. We also found that in young subjects, clinical ones as compared to healthy ones show significantly higher scores of DP phenomena as it could be expected. Also, in our clinical sample no differences were found between young and older subjects: DP symptoms were shown to be equally distributed. As previously noticed, in assessing DP symptoms, besides CDS total score, we also considered two of four factors extracted by a previous factorial analysis [6]: Unreality of Self and Anomalous Body Experiences. Recent empirical and psychopatological works show that certain cognitive symptoms and anomalous body experiences are psychopatological features which could be of substantial importance for the issue of early identification of subjects at risk of transition to major psychiatric disorders [37]. We must admit that such feelings which include cenesthesias, body abnormal feelings, physical discomfort, and body sensations, and are very difficult for the patient to describe and for the clinician to recognize, having a clear color of “unusual” and “strangeness”, could be therefore typical in adolescence. It is very important to note that CDS is not designed to identify more subtle nuances that may help discriminate qualitatively different forms of DP, as for instance DP phenomena that are specific to schizophrenic prodromes, or full-blown schizophrenia, or other anomalies of self- and body-experience typical of bipolar disorder. We can hypothesize that ad hoc scales (e.g., BSABS, EASE, ABPq) may have identified a phenomenological difference between healthy and clinical subjects.
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5. Conclusions Although DP phenomena are more common in subjects with a psychiatric diagnosis of anxiety, depression or psychotic disorder, our study shows that these changes in one's bodily and self experience are also very common in healthy adolescents. In adolescents without a psychiatric diagnosis, DP experiences are likely to be present although in a transient way. Also, their intensity is likely to decrease with age and as one's sense of familiarity with one's body, self and environment is restored. Our results confirm an established view about adolescence, which can be seen as a disturbing period that may be accompanied by uncanny feelings of depersonalization. During adolescence the distress related to one's own bodily feelings and appearance starts to take place. One's image in the mirror is displeasing and every little defect may cause a sense of insecurity. Adolescents may feel their own body almost as something unfamiliar, likely to be judged by others. We may conclude that in adolescence DP is a quasi-physiological, although disturbing phenomenon that occurs rather frequently and in general has a good prognosis. However, since DP phenomena, with a good prognosis in adolescence, are hardly distinguishable at face value from other DP phenomena that may precede severe mental disorders, clinicians should not underestimate the risk of a transition of a subgroup of these ‘healthy’ subjects into some form of psychosis. It is advisable to assess adolescents showing persistent DP phenomena, or at-risk subjects, or subjects with DP and a psychiatric diagnosis, with ad hoc tools designed to evaluate anomalies of self and bodily experience that are specific for psychotic disorders, and especially schizophrenia.
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