Symptom profile and diagnostic utility of depersonalization-derealization disorder: A retrospective critical review from India.

BACKGROUND: Depersonalization and derealization (DPDR) syndrome results from complex interwoven sensory motor experiences seen across psychiatric disorders. There is sparse literature from India on DPDR symptoms, their clinical and research utility. This study focuses frequency of coding the diagnosis of DPDR (ICD-10) and critical discussion about its clinical and research utility.
METHODS: A retrospective review of case files coded under ICD code F48.1 was carried out for 10 years and details were systematically analyzed for age, gender, duration, phenomenology, comorbid diagnosis, and pharmacological treatment.
RESULTS: Fourteen patients received the diagnosis of DPDR. Mean duration of DPDR syndrome was 6 years (standard deviation [SD] = 2.2) while mean age of presentation to hospital was 24 years (SD = 2.5). Tactile imagery (50%), self-environmental integration (42%), and dream-reality integration (28%) were the major themes. Selective serotonin reuptake inhibitors were used as primary medication for 65% of patients.
CONCLUSION: Isolated DPDR syndrome has been diagnosed very rarely in recent past. Reasons may include ignoring the comorbid DPDR coding, inability to articulate DPDR symptoms, inadequate documentation and misinterpretation of symptoms or actually less prevalence of DPDR syndrome in India. Considering scanty literature on DPDR as a primary diagnosis, more studies are required to identify the actual prevalence and coding of DPDR in future. Copyright:

INTRODUCTION

Depersonalization and derealization (DPDR) syndrome is often classified under Dissociative disorders. DPDR experience are difficult to understand and interpret due to complexly interwoven sensory-motor experiences resulting from loss of normal integration of perception, identity, memory and various other faculties of consciousness.[1] In simple words, Depersonalization means feeling of disconnected from self and derealization means feeling of disconnected from an immediate environment.[2] DPDR experiences can range from commonly seen perceptual amnesias to possible psychopathologies associated with horrified feeling of disconnectedness from self and environment. As a component of normal defensive reaction, it is not uncommon to exhibit DPDR symptom in the form of forgetfulness, mind wandering, day dreaming etc. DPDR symptoms have been reported in conditions like substance intoxication (predominantly ketamine, LSD, and hallucinogens), aura of epilepsy, acute and transient psychotic disorders and ecstatic state of mania.[34] It is not uncommon to find these symptoms as an additional specifier for posttraumatic stress disorder (PTSD), panic disorder and Borderline personality disorders among clinical diagnoses.[5] DPDR symptoms are also quite common in patients with acute stress disorder, generalized anxiety disorder and sometimes in severe mental disorders like bipolar disorder, schizophrenia and obsessive-compulsive disorder (OCD).[6]

Prevalence of severe depersonalization are markedly lower (1%) in the general population[7] while clinically significant depersonalization syndrome range from 0.8% to 3.8% across the world.[8] Questionable requirement of DPDR as a separate diagnosis has not been studied so far in the literature. There is dearth of phenomenological understanding about DPDR symptoms and hard to find such literature from India apart from individual case reports. This study was undertaken to find out facts and figures of DPDR syndrome as a primary diagnosis, frequency of reporting the diagnoses of DPDR as per ICD-10 (most commonly followed diagnostic system in India), critical discussion about clinical coding of DPDR diagnoses and future implications of the results. This study justifies the enquiry of documented symptoms of DPDR and their prevalence in India to fill our knowledge gap.

Much of these DPDR experiences form a part of routine day to day activities until they start disturbing normal functions as in certain predisposed individuals. Separate categorization of various dissociative disorders includes dissociative motor disorders, dissociative sensory disorders, dissociative convulsions, dissociative stupor, dissociative amnesia, dissociative fugue, Trans and possession syndromes and DPDR syndromes.[9] Objective of this research is to understand the frequency of coding of DPDR as a diagnosis and to elucidate demographic and psychopathological status of DPDR in patients attending tertiary psychiatry institute. Aim of the study was to find out an importance of missing DPDR diagnosis (ICD-10) from clinical and research perspective. In order to check the frequency and co-occurrence of this diagnostic entity we did a retrospective review of files as discussed below.

METHODS

A retrospective search of case files was carried out using electronic medical record system. Institute ethics committee approval was granted for the research. The search system is equipped with search of only those disorders coded under ICD-10. Every patient seen in outpatient or inpatient is coded under ICD-10 by treating team as per the institute norms. The search code for our study was F48.1, code for the diagnosis of DPDR disorder. The search was carried out retrospectively for 10 years from the year 2005 to 2014. The total number of case files filtered by this code were systematically analyzed by two psychiatrists using an electronic semi-structured pro forma. The details about DPDR were noted including age, gender, duration of DPDR symptoms, phenomenological themes/description of DPDR symptoms, comorbid diagnosis with DPDR, pharmacological treatment, and follow-up care.

RESULTS

On an average, 140,000 psychiatry files were coded in 10 years. We found that only 14/140,000 (0.01%) patients actually received primary psychiatric diagnosis of DPDR syndrome over a period of 10 years which is far below the expected prevalence according to available literature.[4] Males were overrepresented in terms of receiving the diagnosis of DPDR, almost 2.5 times that of females. Eighty-five percent of them were managed on outpatient services while 15% required IP care. Mean duration of DPDR syndrome at the time of diagnosis was 6 years (standard deviation [SD] =2.2) while mean age of presentation to hospital was 24 years (SD = 2.5) and is quite consistent with the literature.[10] Seventy-two percent had comorbid secondary psychiatric diagnosis predominantly anxiety and depressive spectrum disorders while only 28% had isolated DPDR syndrome. The information was available as Institute coding follows norm of primary diagnosis followed by secondary diagnosis. Hence, when DPDR appears first in the coding sequence, it is taken as primary diagnosis. The major themes of DPDR documented in the case files were tactile imagery (50%), self-environmental integration (42%), dream-reality integration (28%), dysmegalopsia (25%), near-death experience (14%) and Deja phenomenon (35%) which included multiple complex themes with multisensory involvement [Figure 1].[11] Selective serotonin reuptake inhibitors (SSRI) were used as primary medication for 65% of patients followed by serotonin norepinephrine reuptake inhibitors (SNRI) and antipsychotics in our finding. Follow up notes in the file were carefully assessed for information on frequency of follow up, response to treatment, change in treatment and change of diagnosis. Out of 14 patients, 6 responded to primary pharmacotherapy and visited every 2 monthly to hospital which is similar to patients with other diagnoses in the institute. Five patients visited only twice and responded well to primary treatment as per follow up records. Three patients required addition of Lamotrigine 200 mg/day, Carbamazepine 400 mg/day and Naltrexone 50 mg/day respectively for the control of DPDR symptoms. Additionally 2 of them were found to have anankastic traits and alexithymia, respectively. None of the patient had change in the diagnosis during follow-up.

Figure 1

Frequency of depersonalisation-derealisation themes

DISCUSSION

Males outnumbering females is contrary to the conventional findings of previous studies which suggest that female patients tend to have more DPDR like experience.[12] Long duration of DPDR experience before seeking professional help suggests individual's inability to cope with such experience over time, underestimating the abnormal experience or possible anxiety and inability to report the symptoms. DPDR symptoms are often comorbid with Depression, Anxiety, OCD and PTSD which was consistent with our findings.[13] DPDR symptoms are complex amalgamation of perceptual and memory functions which are blended to produce altered self-identification. According to ICD-11, these symptoms should produce significant distress or impairment in personal, family, social, educational, occupational or other important areas of functioning.[14] From neurobiological perspective, de-differentiation is another term described secondary to difficulty in orchestrating different neurosensory inputs during dream and wakeful state. Such inability to distinguish between two states of consciousness can result in significant mind-body confusion giving rise to DPDR like symptoms[15] that are summarized in Table 1. The discussion about overlapping states of dream and wakefulness is beyond the scope of this article.

Table 1

Description of themes and symptoms of depersonalization and derealization syndrome

Themes	Description of DPDR symptoms
Depersonalization	A strong sense of disconnectedness from self (as if they are in a dream or are watching themselves in a movie)
Derealization	A strong sense of disconnectedness from an atmosphere (as if the state is dreamlike, distant, foggy, lifeless, colorless, or visually distorted)
Near-Death Experience	Extreme sense of absolute dissolution, flash of a light accompanied by perception of leaving one’s body and suddenly finding oneself back inside one’s body
Dysmegalopsia	Experiencing change in spatial form of an object resulting in an inability to judge the size or measure of an object accurately, also called as dysmetropsia
Dream-Reality Integration	A strong sense of connectedness with dream experience
Self-Environmental Integration	A strong sense of connectedness to surrounding environment
Tactile imagery	Feeling of tactile sensation while describing a visual stimulus in the form of imagery
Deja vu	Experience of revisiting a new situation
Jamais vu	Experience of feeling an old situation a completely new one
Deja entendu	Experiencing of re-listening a new word or story
Jamais entendu	A false experience of unfamiliarity to familiar sounds or words
Deja pense	Completely new thoughts are experienced as old one
Deja vecu	Experience of predicting next event based on current revisiting of a new situation with the help of environmental clues like smell, taste etc.
Deja visite	Experience of revisiting a completely new place
Deja senti	Experience of finishing uttering a word and immediately realizing that you actually did not speak it
Presque vu	Experience of tip of the tongue phenomenon very often creating a distress

DPDR – Depersonalization and derealization

In the absence of pharmacological treatment guidelines for DPDR syndrome, use of SSRI, SNRI and antipsychotics is justified in our finding.[16] Also use of benzodiazepines and other agents is not unusual in DPDR symptoms. However on the flipside there is paradoxical reproduction of DPDR like symptoms as a part of an adverse effect of some of the treatments used in the management of DPDR which makes DPDR an interesting phenomenon altogether.[17] Lamotrigine, Naltrexone and repetitive transcranial magnetic stimulation appears to have some add-on benefits in modulation of these symptoms, though treatment of DPDR is beyond the scope of this article.

Our study findings reflected that isolated DPDR syndrome has been diagnosed very rarely in recent past and often co-exists with depressive and anxiety spectrum disorders.[12] It is possible that DPDR as a comorbid diagnosis might have been ignored during coding of the files resulting in lesser frequency of DPDR in our study. Patients with DPDR syndromes are not able to find exact words to express their symptoms which may result in inadequate documentation and classification of phenomenology.[18] It is also possible that emphasis on severe mental illnesses can undermines the importance of eliciting DPDR symptoms among residents. It is also possible that DPDR symptoms are rarely reported by patients because of minimal distress, inability to articulate symptoms or reporting phenomenological bias. Misinterpretation of DPDR symptoms by Psychiatrist into hallucinations, illusions or delusions can also be a contributing factor for lesser frequency of diagnosing primary DPDR in recent years. On the other hand, it is also possible that DPDR symptoms are actually less prevalent in India. Findings of this study set an argument regarding frequency of occurrence of DPDR syndrome, its clinical coding, and slight gender skewing from the literature. The current study being a single-center retrospective design, limits the generalizability of results. However, in the context of diagnosing DPDR syndrome and describing its phenomenology in detail, this is the first study of its kind from India.

One can look forward to find possible ways to earmark DPDR disorders for naturalistic follow up studies using structured interview schedules to get accurate numbers. It also questions why do very few patients receive isolated DPDR diagnosis?, what makes the boundary blurred from normalcy to pathology? and why do the patients with DPDR show poor treatment response?[1920] As a matter of fact it has been seen that DPDR symptoms can be strongly associated with creativity and splinter skills.[21] DPDR state is also a transitory altered state of consciousness can open a new channel of research on consciousness and hence more robust evidence is needed to question their utility in clinical practice. It is clear that DPDR experiences are complex dissociative experiences where normal ego boundaries tend to disintegrate momentarily while keeping insight into the experience unlike the one in psychotic disorders. Recent evidence also suggests link between development of psychotic symptoms and depersonalization.[22] It is quite possible that DPDR symptoms would be given more importance in the future considering the importance of overlapping horizon of different states of consciousness.

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Conflicts of interest

There are no conflicts of interest.