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This article has been mentioned numerous times over the years, but having read through it recently I thought I would post it in full. As it's an old article and fully credited I don't expect any copyright complaints, but should anyone have any I will take it down.
Acta psychiat. scand. (1978) 58, 191-198
Department of Psychiatry (Head E. J. McCranie, M.D.), Medical College of Georgia,
Augusta, Georgia, USA
Review of the relationship between obsession and
depersonalization
E. M. TORCH
Depersonalization is discussed and a brief outline of the primary
symptoms is presented. The relationship between obsessionalism
and depersonalization is reviewed in the literature, and subsequent
similarities are presented. The intellectual obsessive depersonalization
syndrome is postulated as a variant, and also as an exposition
of what might occur in many other cases of depersonalization.
Finally, a picture is presented which takes into account a strong
component of obsessionalism in both the etiology and course of
depersonalization.
Key words: Depersonalization - obsession - anancasm - depression.
I
Depersonalization is a complex syndrome found in numerous emotional disorders,
ranging from a separate, isolated neurosis to a progenitor or concomitant
syndrome of various psychotic disorders. It is being diagnosed with increased
frequency as psychiatrists recognize its various presentations and manifestations.
Cuttell (1966) has described depersonalization as the third most frequent emotional
problem encountered in a mental hospital after depression and anxiety.
Nor is depersonalization purely confined to a so-called “abnormal” populace, as
Dixon’s (1963) study of college students revealed that 46 % of his sample had
experienced depersonalization during a single year.
It need not be pointed out that depersonalization is a trying and exceedingly
difficult syndrome to bring into remission, much less cure. Patients often complain
year after year of a changed way of experiencing internal reality and the
“concreteness” of the external world. Numerous authors cite patients with a
duration of symptoms of 20-30 years. In fact, it can almost be stated a priori,
whether the depersonalization is a separate syndrome or a “forme fruste” of
schizophrenia, that the degree of depersonalization present in the forefront of
the clinical picture will almost inversely affect the time necessary to begin any
meaningful insight therapy. As most have found who must daily or weekly deal
with the seriously depersonalized patient, therapy frequently centers on the vain
efforts of the patient to explain his estrangement, or a reporting of the intense
psychic pain which is so common in this syndrome (paradoxically, these patients
will also be preoccupied with their pronounced loss of affect when dealing with
any subject other than their depersonalization!).
Therefore, a worthwhile and obvious question remaining to be answered is
“why?” Why is this condition so refractory to treatment? In an attempt to
answer this question, one must look towards the first step; a viable etiology. In
psychiatry, more than any other branch of medicine, one finds that the etiological
factors in the disorder can not only determine the course of the illness but the
outcome as well.
This paper addresses itself towards finding a common etiological factor in the
literature, and will also seek to expand this into a working hypothesis for explaining
those factors found in depersonalization which make it so difficult to
treat.
Depersonalization, for the purposes of this paper, will be a term reserved for
a syndrome which possesses the following characteristics:
(1) A feeling of change throughout, of estrangement from the self, and usually,
though not always, a feeling of total change in subjective perception of the
external world.
(2) There is a distinct feeling of unreality present, which shades most of the
patient’s clinical picture. Despite the feelings of unreality present, the feelings
are perceived and described in a non-delusional and ego-dystonic manner,
with an “as if“ quality to them.
(3) The patient interprets the feelings as being distinctly unpleasant.
(4) There is a perplexing and curious subjective report (usually not verified h
objective testing) of a change, usually a diminution, of affect, though the
patient will remain quite able to experience discomfort in his depersonalization.
It is the feeling of the author that the ubiquitous nature of this syndrome with
the myriad forms observed justifies a rather broad interpretation of the above
criteria. They are in no sense strictly limited in definition and scope.
Early on in psychiatry, Freud had described feelings of depersonalization in
his patients and was later to write of his own feelings upon viewing the Acropolis
(Freud (1941)). Later psychoanalytic theorists such as Sadger (1928), Nunberg
(1924), Reik (1927), Federn (1928) and Oberndorf (1934) also discussed various
types of dissociation and depersonalization.
Over and over, in these early papers, there is a stress on self-observation and
hypochondriasis. Only occasionally do the early theorists speculate on which of
these appears first in depersonalization.
It remained for Schilder (1939) to fully explore this early analytical trend towards
the view that the dissociation of the personality into observer and participant
with hypochondriacal self-observation was at the center of the symptomatology.
“Hypochondriacal features are to be found practically in every case of depersonalization
... I am inclined to stress the fact that the patient with depersonalization has
been admired very much by the parents for his intellectual and physical gifts. A great
amount of admiration and erotic interest has been spent upon the child. He expects
that this erotic inflow should be continuous ... Dissatisfaction has to ensue even if the
parents live in a state of continual admiration of the child since every such relation
does not consider the child as a total human being but merely as a show piece ... by
identification with the parents, self-observation will take the place of the observation
by others.”
The trend here is clearly one of obsessionalism. Prominent mention is made by
most of these analysts of a type of narcissism which is quite hard to distinguish
from the anal character, rather than the so-called “pre-genital” hysterical character
now in vogue in the literature.
Schilder (1950) later pointed out that libido seems to be fixed neither on an
external object nor in the self:
“All depersonalized patients observe themselves continuously and with great zeal; they
compare their present dividedness-within-themselves with their previous oneness-with-themselves.
Self-observation is compulsive with these patients. The tendency to self-observation
continuously rejects the tendency to live, and we may say it represents the
internal negation of experience.”
So as much as any one factor in the syndrome described by these early analytical
studies, obsessional characteristics seem to be in the forefront of the clinical picture,
and Schilder considered his patients to be extremely obsessional personalities.
We must now ask just whether there could be a syndrome occurring in other
than an obsessional setting, because even though authors such as Roth (1959)
see a clear line between obsessional neuroses and depersonalization, and depersonalization
is seen in many conditions other than, and even rarely in, obsessional
neuroses, there seems to be a definite link between obsessional self-observation
and depersonalization.
This observation is by no means new to psychiatry, and much research has
been done on the problem. Shorvon (1946) reports obsessional traits in 88 %
of his now classic series of cases. Another landmark investigation by Roth
(1959) notes nearly 75 % strongly premorbid obsessional traits, and he proceeded
to describe the pre-depersonalization personality as being dependent, rigid, immature,
quite obsessional with chronic anxiety and numerous phobias. These
patients are seen as conscientious, scrupulous individuals, with a strong liking
for order and routine. Almost all of Davison’s (1964) seven cases of “depersonalization
syndrome” have strong obsessive features.
Indeed, Skoog (1965), perhaps the foremost authority on the relation between
“anancasms”, the “anancastic-sensitive” personality (i.e. insecure, sensitive, rigid
individuals, prone to obsessional thought) and depersonalization literally finds
anancasms and depersonalization reactions impossible to differentiate at times:
“Depersonalization is a typical and common symptom of anancasms where the loss
of security and spontaneity can be studied from both specific and essential angles ...
depersonalization can in most cases be discerned at the very onset of the anancasms.
Often it appears in the form of acute anxiety-laden changes in perception of the body.
But it may also manifest itself in cloudy states of bewilderment and doubt - there are
several qualitative similarities between depersonalization and anancasms. This applies
particularly to intellectual obsessions, e.g. obsessive doubt and rumination . .. the patient
does not stop at any fixed anxiety or phobia, he is driven by his agony to get to
the bottom of his experience. In this stage of the onset of anancasms, depersonalization
and obsession merge with one another phenomenologically, so that the patient in a
dizzy paradox experiences both a feeling of alienation and a reinforced feeling of
reality.
Obviously, the subject matter of obsessions are as varied as the subjects of
thought available to the human mind. But, as pointed out by Skoog (1965) and
many others, there is a particular type of patient whose obsession is observing
himself or his “vegetative functions”. Even in a typical case of hypochondria,
conversion neurosis or depression, in the background of an obsessional personality
it is not hard to see how continual, repetitive preoccupation with one’s self
can lead to a feeling of unreality, based in no small way on the fact that even
to a philosopher (or neuroanatomist), the question of just where to locate centrality
of ‘‘self” or “being” is an uncomfortable one to face. It simply becomes
impossible to fathom in some patients of this type whether compulsive self-observation
preceded depersonalization or resulted from an initial episode of
depersonalization in the introspective obsessional patient. This will be discussed
in greater detail shortly.
Lion’s (1942) patients were primarily depressed, with strongly rigid and obsessional
personalities. In seeking to alleviate obsessional depression, Lion mentions
that in his patients “there were various ways of experiencing this content
which suddenly possessed them as if it were a foreign body that invaded the
organism. They become introspective, and ideas of unreality set in”.
There seems to be little doubt that, even when depersonalization occurs in an
illness not associated with an obsessional personality or obsessional neurosis,
it is manifested in a strongly obsessional manner, and therein lies the rub, so
to speak. The psychiatrist is faced with dealing with an obsessional illness with
the self as the core content, and all of the extremely distressing questions which
unending self-observation yields in the intelligent or frightened (or usually both)
patient. And even the layman can detect a very noted pessimism in psychiatric
literature concerning the treatment of the obsessional personality, or even worse,
the obsessive neurosis.
II
Before proceeding to the further implications of this in depersonalization, I
would like to discuss a particular variant, which I call the intellectual-obsessive
depersonalization syndrome. Because it is usually found to occur in highly intelligent,
introspective people, we are often provided with a “blow-by-blow” description
of the mechanisms which may enter into forming a depersonalization
reaction.
The syndrome of intellectual-obsessive depersonalization is composed of a
complex and fascinating combination of alternating states of depersonalization
and obsessive self-scrutiny. It is commonly found in young men with highly
obsessive premorbid personalities, and often in philosophers, mathematicians,
psychologists and psychiatrists, all of whom are inclined to ruminate on the
intrinsic meaning of things.
While intellectual preoccupations and obsessions may be in the forefront of
the clinical picture, depersonalization and associated feelings of unreality may
be at the core. In fact, there is a constant spiraling intertwining of the two.
Many North American psychiatrists view intellectual-obsessive depersonalization,
as the syndrome is sometimes called in the Scandinavian literature (particularly
in the works of Skoog), as pseudoneurotic schizophrenia or “borderline” syndrome,
weighing all factors of the disease equally. In fact, most of the symptoms
of pan-anxiety, stoppages of thought processes, etc., may be the result
of an episode of depersonalization in a highly introspective, obsessive personality.
The syndrome has these components: an initial, but long-lasting feeling of
depersonalization, depriving the person of a base for processing meaningful existence;
derived from a period of hypochondriacal self-scrutiny and finally, a
total denial of “being”, which represents the summation effect of the wounds
encountered previously. The end result is a picture of the “burned out” depersonalization
patient who, although still fully in touch with reality, refuses to
acknowledge its intrinsic meaning.
At the beginning of the I.O.D. syndrome, the patient is the victim of the
same circumstances which characterize any other patient with depersonalization
as a specific neurosis. The onset is usually abrupt, the feelings are those of
giddiness or bewildered puzzlement, which soon give way to feelings of numbness
and “the uselessness of it all.” The patient will report that in an inexplicable
manner, he is changed throughout and cannot see events in the same
light as before. As yet, however, the patient will quite certainly show emotionality
despite the fact that he denies having any emotions. Concurrently, he will show
certain metaphysical preoccupations, or at least what appear to be preoccupations.
In actuality, the patient is still scanning his nearly blank internal environment.
It is at this stage, however, that the depersonalization syndrome separates
into two distinct entities, with most patients remaining immobilized by the
feelings of unreality. Usually, in the patient who is a female, of low status in
education, or not inclined towards introspection, the feelings of unreality pre
dominate.
In another type of patient, one who is likely to be highly educated, male,
and already extremely prone to introspection, the feelings of unreality take a
secondary stance in favor of morbid self-preoccupation. The fuse, feelings of
unreality, sets off the explosion: metaphysical preoccupation with nothingness.
The patient is likely to dwell endlessly on the meaning of time, self, consciousness,
emotion, or moral values. Intrinsic in his arguments will likely be a strange,
winding path of hyperconsciousness, depersonalization and active, though nongenuine,
reliving of both states through memory. In this manner, layer upon
layer of symptomatology begins to build up, and will soon overshadow the feelings
of unreality which are at the root of the problem.
Finally, the patient will progressively dissect his experiences in the ultimate.
The projected attitude is one of lessening depression, decreasing anxiety, but
unfortunately, almost totally detached introspection. This metaphysical world,
in which we all inhabit different levels of reality, does not stand up to scrutiny
of the magnitude to which it is subjected by these patients. It is one thing to
question worth, yet another to constantly question why worth is needed. It is
necessary to examine one’s emotions, but emotions become unreal qualities when
subjected to such questions as, “Where is emotion received?”, or “HOW is it that
I sense any feeling at all?” and finally, “By what substrate is emotion carried
from one part of the brain to another?”, in the words of one patient whose
occupation was that of a neuroanatomist. The peculiar, and ultimately indescribably
complex tie to sanity and willed thought which contains meaning
for the individual vanishes for these unfortunate patients, as a consequence of
the above-mentioned symptomatology and the basic, never-changing feelings of
not possessing ‘Lwholeness”, “oneness”, or “feet planted firmly on the ground”,
which is the original complaint of nearly all depersonalized patients.
The veil which separates the depersonalized patient from his world now contains
so many components that it becomes nearly impossible to repair damage
which could cause depersonalization, because of the strewn wreckage of various
metaphysical remnants which the patient has in his repertoire. Depersonalization
has forced an already highly introspective character to stand back and examine
“being” itself, and all of its characteristics, most of which are inexacting and
nebulous in the extreme, even to those of us who claim rationality. Thus these
people are actually changed in two ways: They are still depersonalized, and as
a result of their neurotic state, they are faced with problems which most of us
seldom have to face (e.g. the essential absurdity of any aspect of existence when
examined for too long with too much intensity).
Even as unlikely, or perhaps ephemeral, as this syndrome is beginning to
sound, there is more than ample precedence in the literature.
Slater & Roth (1969) speak of a “primary depersonalization syndrome ... the
depersonalization does not appear to be secondary to some other psychiatric
disorder, although difficulty in establishing personal relationships and in negotiating
adolescence in general, and an abnormal degree of self-absorption, withdrawal
into fantasy or rumination about fate, time and death are common
features.”
Roberts (1960) provides several vivid eye-witness accounts of depersonalization
in a sample of college students: “There is a feeling of extreme fatigue, and an
inability to cope with or be interested in persons or things - coupled with
emotional distress at this inability ... as soon as I relax I get an intense feeling
of (‘Me” being located in my brain just behind my eyes. I am extremely aware
of myself as being alive and existing in this particular place, but the rest of
my head and body - except my eyes - does not belong to “Me”. My body is
felt as a pure biological machine automatically pumping food and air to keep
alive my brain.”
Another student reflected, “My impression was that I did this to reassure myself
- bring myself back. The most striking feeling being that I did not know
what a person was. In other words I was saying to myself, ‘I am a human
being and my name is S..., but whereas this would normally have been a
joke or a tautology because I could not imagine anything else, it here took on
significance because of having a feeling of strangeness - that is, that it could
be questioned’.”
Roberts (1960) states: “in perceptual development the non-introspected self
(the imaginer) comes to set up a self-image, using the body as a fundament, to
form an object of the body, and to complete external perception by representation
in objects ... In dp (depersonalization) there is an absence of the self-image.
The persistent need to apprehend the self, results in ceaseless and useless
self-scrutiny.”
Skoog (1965) points to numerous studies relating rather philosophical obsessions
with inadequate feelings of self and depersonalization as predecessors:
“Doubt or uncertainty is the key word even for patients with depersonalization. It
is also the patient with obsessive doubt and related anancasms who most exhibits the
feeling of unreality vis a vis the “self” and environment. The perseveration tendency
in anancasts is certainly a contributory factor: repetitive experience of general insecurity
results in a feeling of estrangement from the objects of reality - existence
is no longer so concrete, it loses substance and becomes misty and dream-like. The
feeling can gradually crystallize into brooding and doubt anancasms which, owing to
their monotony of perseveration, accentuate the insufficiency of contact with “reality”
still more ... Such connections were so common in my material that it appears difficult
to distinguish between anancasms and depersonalization. The patients experience
their unreality phenomena as shrouds d anancastic doubt - “It is as if I were not
mentally present. Do I really exist?” ... In obsessive rumination ... the anancasm
is often nothing but a monotonous, perseveratory compulsive repetition of depersonalization
symptoms manifesting themselves as subjective corpora aliene in an otherwise
adequate experience. “What is a human being?” - “What is this?” (the patient
embraces himself with his arms) - “Why me?” - “Why do just I live?” - “Why is the
wall painted green and not some other color?” - the obsessive questioning can in
principle never get any answer, never find any rest, the perseveration goes on and on,
unreality persists and the anancasms become fixated.”
III
While we see from the above descriptions that depersonalization can take on
a rather esoteric picture, possessing a focus on intellectual and rather metaphysical
questions, what seems to be present in a rather unequivocal manner
is that in nearly all cases of depersonalization, it is the obsessional nature of
the syndrome which seems to provide the drive and the “staying power” to the
syndrome.
In depersonalization, self-observation is listed as a concurrent or resultant
symptom. It is usually, rather, a primary causative factor. We have seen that the
majority of patients who experience depersonalization syndromes are quite obsessional
in personality type. Throughout the illness, most of the patients are
prone to relate the focus of anxiety to themselves, to ask the question (perhaps
even consciously), “What is wrong with me?”. As we have seen the depersonalized
patient progress from the beginning of the syndrome, these steps seem to
be present in most, if not all cases:
A. Predisposition to obsessional thinking, with high standards of self-acceptabil-
ity and almost predictable low self-esteem.
B. Doubt, uncertainty, and strong introspective features.
C. A consequential repetitive experience of insecurity.
D. Refocusing of the insecurity on the self and the self in the world, perhaps
secondary to trauma or chronic stress.
E. Obsession with the self.
F. Failure of the self to withstand such rigorous self-scrutiny.
G. Depersonalization, with depression and anxiety.
H. Exacerbation of feelings of unreality and self-estrangement.
I. Further obsessive defenses and the heightened experience of unreality.
REFERENCES
Cattell, J. P. (1966): Depersonalization phenomena. In Arieti, S. (ed.): American hand-
Davison, K. (1964): Episodic depersonalization: Observations of seven patients. Brit. J.
Dixon, I. C. (1963): Depersonalization phenomena in a sample population of college
Federn, P. (1928): Some variations in ego-feeling. Int. J. Psycho-Anal. 7, 434.
Freud,S. (1941): A disturbance of memory on the Acropolis (1936). Translated by
Lion, E. G. (1942): Anancastic depression. J. new. ment. Dis. 95, 730-738.
Nunberg, H. (1924): Uber Depersonalisations-Zustande im Lichte der Libidotheorie. Int.
Oberndorf, C. P. (1934): Depersonalization in relation to erotization of thought. Int. J.
Reik, T. (1927): Wie man Psychologe wird. Internationaler Psychoanalytischer Verlag,
Roberts, W. W. (1960): Normal and abnormal depersonalization. J. ment. Sci. 106,
Rorh, M. (1959): The phobioanxiety depersonalization syndrome. Proc. roy. SOC. Med.
Sadger, I. (1928): Uber Depersonalisatioa. Int. Z. Psychoanal. 14, 315.
Schilder, P. (1939): The treatment of depersonalization. Bull. N.Y. Acad. Med. 52,
Schilder, P. (1950): The image and appearance of the human body. International Uni-
Shorvon,H.J. (1946): The depersonalization syndrome. Proc. roy. SOC. Med. 39, 779-
Skoog, G. (1965): Onset of anancastic conditions. Acta psychiat. scand., Suppl. 184,
Slater, E., & M. Roth (1969): Clinical psychiatry. WiIIiams & Wilkins, Baltimore, p. 121.
Received December 27, 1977
book of psychiatry. Basic Books, New York, pp. 766-799.
Psychiat. 110, 505-513.
students. Brit. J. Psychiat. 109, 371-375.
Strachey, J. Int. J. Psycho-Anal. 22(2), 93-101.
Z. Psychoanal. 10, 17.
Psycho-Anal. 15, 271.
Leipzig.
478493.
52, 587-595.
587-595.
versities Press, New York, pp. 138-141.
792.
67-78.
Evan M. Torch, M.D.
Department of Psychiatry
Box 1810, Medical College of Georgia
Augusta, Georgia 30902
USA
Acta psychiat. scand. (1978) 58, 191-198
Department of Psychiatry (Head E. J. McCranie, M.D.), Medical College of Georgia,
Augusta, Georgia, USA
Review of the relationship between obsession and
depersonalization
E. M. TORCH
Depersonalization is discussed and a brief outline of the primary
symptoms is presented. The relationship between obsessionalism
and depersonalization is reviewed in the literature, and subsequent
similarities are presented. The intellectual obsessive depersonalization
syndrome is postulated as a variant, and also as an exposition
of what might occur in many other cases of depersonalization.
Finally, a picture is presented which takes into account a strong
component of obsessionalism in both the etiology and course of
depersonalization.
Key words: Depersonalization - obsession - anancasm - depression.
I
Depersonalization is a complex syndrome found in numerous emotional disorders,
ranging from a separate, isolated neurosis to a progenitor or concomitant
syndrome of various psychotic disorders. It is being diagnosed with increased
frequency as psychiatrists recognize its various presentations and manifestations.
Cuttell (1966) has described depersonalization as the third most frequent emotional
problem encountered in a mental hospital after depression and anxiety.
Nor is depersonalization purely confined to a so-called “abnormal” populace, as
Dixon’s (1963) study of college students revealed that 46 % of his sample had
experienced depersonalization during a single year.
It need not be pointed out that depersonalization is a trying and exceedingly
difficult syndrome to bring into remission, much less cure. Patients often complain
year after year of a changed way of experiencing internal reality and the
“concreteness” of the external world. Numerous authors cite patients with a
duration of symptoms of 20-30 years. In fact, it can almost be stated a priori,
whether the depersonalization is a separate syndrome or a “forme fruste” of
schizophrenia, that the degree of depersonalization present in the forefront of
the clinical picture will almost inversely affect the time necessary to begin any
meaningful insight therapy. As most have found who must daily or weekly deal
with the seriously depersonalized patient, therapy frequently centers on the vain
efforts of the patient to explain his estrangement, or a reporting of the intense
psychic pain which is so common in this syndrome (paradoxically, these patients
will also be preoccupied with their pronounced loss of affect when dealing with
any subject other than their depersonalization!).
Therefore, a worthwhile and obvious question remaining to be answered is
“why?” Why is this condition so refractory to treatment? In an attempt to
answer this question, one must look towards the first step; a viable etiology. In
psychiatry, more than any other branch of medicine, one finds that the etiological
factors in the disorder can not only determine the course of the illness but the
outcome as well.
This paper addresses itself towards finding a common etiological factor in the
literature, and will also seek to expand this into a working hypothesis for explaining
those factors found in depersonalization which make it so difficult to
treat.
Depersonalization, for the purposes of this paper, will be a term reserved for
a syndrome which possesses the following characteristics:
(1) A feeling of change throughout, of estrangement from the self, and usually,
though not always, a feeling of total change in subjective perception of the
external world.
(2) There is a distinct feeling of unreality present, which shades most of the
patient’s clinical picture. Despite the feelings of unreality present, the feelings
are perceived and described in a non-delusional and ego-dystonic manner,
with an “as if“ quality to them.
(3) The patient interprets the feelings as being distinctly unpleasant.
(4) There is a perplexing and curious subjective report (usually not verified h
objective testing) of a change, usually a diminution, of affect, though the
patient will remain quite able to experience discomfort in his depersonalization.
It is the feeling of the author that the ubiquitous nature of this syndrome with
the myriad forms observed justifies a rather broad interpretation of the above
criteria. They are in no sense strictly limited in definition and scope.
Early on in psychiatry, Freud had described feelings of depersonalization in
his patients and was later to write of his own feelings upon viewing the Acropolis
(Freud (1941)). Later psychoanalytic theorists such as Sadger (1928), Nunberg
(1924), Reik (1927), Federn (1928) and Oberndorf (1934) also discussed various
types of dissociation and depersonalization.
Over and over, in these early papers, there is a stress on self-observation and
hypochondriasis. Only occasionally do the early theorists speculate on which of
these appears first in depersonalization.
It remained for Schilder (1939) to fully explore this early analytical trend towards
the view that the dissociation of the personality into observer and participant
with hypochondriacal self-observation was at the center of the symptomatology.
“Hypochondriacal features are to be found practically in every case of depersonalization
... I am inclined to stress the fact that the patient with depersonalization has
been admired very much by the parents for his intellectual and physical gifts. A great
amount of admiration and erotic interest has been spent upon the child. He expects
that this erotic inflow should be continuous ... Dissatisfaction has to ensue even if the
parents live in a state of continual admiration of the child since every such relation
does not consider the child as a total human being but merely as a show piece ... by
identification with the parents, self-observation will take the place of the observation
by others.”
The trend here is clearly one of obsessionalism. Prominent mention is made by
most of these analysts of a type of narcissism which is quite hard to distinguish
from the anal character, rather than the so-called “pre-genital” hysterical character
now in vogue in the literature.
Schilder (1950) later pointed out that libido seems to be fixed neither on an
external object nor in the self:
“All depersonalized patients observe themselves continuously and with great zeal; they
compare their present dividedness-within-themselves with their previous oneness-with-themselves.
Self-observation is compulsive with these patients. The tendency to self-observation
continuously rejects the tendency to live, and we may say it represents the
internal negation of experience.”
So as much as any one factor in the syndrome described by these early analytical
studies, obsessional characteristics seem to be in the forefront of the clinical picture,
and Schilder considered his patients to be extremely obsessional personalities.
We must now ask just whether there could be a syndrome occurring in other
than an obsessional setting, because even though authors such as Roth (1959)
see a clear line between obsessional neuroses and depersonalization, and depersonalization
is seen in many conditions other than, and even rarely in, obsessional
neuroses, there seems to be a definite link between obsessional self-observation
and depersonalization.
This observation is by no means new to psychiatry, and much research has
been done on the problem. Shorvon (1946) reports obsessional traits in 88 %
of his now classic series of cases. Another landmark investigation by Roth
(1959) notes nearly 75 % strongly premorbid obsessional traits, and he proceeded
to describe the pre-depersonalization personality as being dependent, rigid, immature,
quite obsessional with chronic anxiety and numerous phobias. These
patients are seen as conscientious, scrupulous individuals, with a strong liking
for order and routine. Almost all of Davison’s (1964) seven cases of “depersonalization
syndrome” have strong obsessive features.
Indeed, Skoog (1965), perhaps the foremost authority on the relation between
“anancasms”, the “anancastic-sensitive” personality (i.e. insecure, sensitive, rigid
individuals, prone to obsessional thought) and depersonalization literally finds
anancasms and depersonalization reactions impossible to differentiate at times:
“Depersonalization is a typical and common symptom of anancasms where the loss
of security and spontaneity can be studied from both specific and essential angles ...
depersonalization can in most cases be discerned at the very onset of the anancasms.
Often it appears in the form of acute anxiety-laden changes in perception of the body.
But it may also manifest itself in cloudy states of bewilderment and doubt - there are
several qualitative similarities between depersonalization and anancasms. This applies
particularly to intellectual obsessions, e.g. obsessive doubt and rumination . .. the patient
does not stop at any fixed anxiety or phobia, he is driven by his agony to get to
the bottom of his experience. In this stage of the onset of anancasms, depersonalization
and obsession merge with one another phenomenologically, so that the patient in a
dizzy paradox experiences both a feeling of alienation and a reinforced feeling of
reality.
Obviously, the subject matter of obsessions are as varied as the subjects of
thought available to the human mind. But, as pointed out by Skoog (1965) and
many others, there is a particular type of patient whose obsession is observing
himself or his “vegetative functions”. Even in a typical case of hypochondria,
conversion neurosis or depression, in the background of an obsessional personality
it is not hard to see how continual, repetitive preoccupation with one’s self
can lead to a feeling of unreality, based in no small way on the fact that even
to a philosopher (or neuroanatomist), the question of just where to locate centrality
of ‘‘self” or “being” is an uncomfortable one to face. It simply becomes
impossible to fathom in some patients of this type whether compulsive self-observation
preceded depersonalization or resulted from an initial episode of
depersonalization in the introspective obsessional patient. This will be discussed
in greater detail shortly.
Lion’s (1942) patients were primarily depressed, with strongly rigid and obsessional
personalities. In seeking to alleviate obsessional depression, Lion mentions
that in his patients “there were various ways of experiencing this content
which suddenly possessed them as if it were a foreign body that invaded the
organism. They become introspective, and ideas of unreality set in”.
There seems to be little doubt that, even when depersonalization occurs in an
illness not associated with an obsessional personality or obsessional neurosis,
it is manifested in a strongly obsessional manner, and therein lies the rub, so
to speak. The psychiatrist is faced with dealing with an obsessional illness with
the self as the core content, and all of the extremely distressing questions which
unending self-observation yields in the intelligent or frightened (or usually both)
patient. And even the layman can detect a very noted pessimism in psychiatric
literature concerning the treatment of the obsessional personality, or even worse,
the obsessive neurosis.
II
Before proceeding to the further implications of this in depersonalization, I
would like to discuss a particular variant, which I call the intellectual-obsessive
depersonalization syndrome. Because it is usually found to occur in highly intelligent,
introspective people, we are often provided with a “blow-by-blow” description
of the mechanisms which may enter into forming a depersonalization
reaction.
The syndrome of intellectual-obsessive depersonalization is composed of a
complex and fascinating combination of alternating states of depersonalization
and obsessive self-scrutiny. It is commonly found in young men with highly
obsessive premorbid personalities, and often in philosophers, mathematicians,
psychologists and psychiatrists, all of whom are inclined to ruminate on the
intrinsic meaning of things.
While intellectual preoccupations and obsessions may be in the forefront of
the clinical picture, depersonalization and associated feelings of unreality may
be at the core. In fact, there is a constant spiraling intertwining of the two.
Many North American psychiatrists view intellectual-obsessive depersonalization,
as the syndrome is sometimes called in the Scandinavian literature (particularly
in the works of Skoog), as pseudoneurotic schizophrenia or “borderline” syndrome,
weighing all factors of the disease equally. In fact, most of the symptoms
of pan-anxiety, stoppages of thought processes, etc., may be the result
of an episode of depersonalization in a highly introspective, obsessive personality.
The syndrome has these components: an initial, but long-lasting feeling of
depersonalization, depriving the person of a base for processing meaningful existence;
derived from a period of hypochondriacal self-scrutiny and finally, a
total denial of “being”, which represents the summation effect of the wounds
encountered previously. The end result is a picture of the “burned out” depersonalization
patient who, although still fully in touch with reality, refuses to
acknowledge its intrinsic meaning.
At the beginning of the I.O.D. syndrome, the patient is the victim of the
same circumstances which characterize any other patient with depersonalization
as a specific neurosis. The onset is usually abrupt, the feelings are those of
giddiness or bewildered puzzlement, which soon give way to feelings of numbness
and “the uselessness of it all.” The patient will report that in an inexplicable
manner, he is changed throughout and cannot see events in the same
light as before. As yet, however, the patient will quite certainly show emotionality
despite the fact that he denies having any emotions. Concurrently, he will show
certain metaphysical preoccupations, or at least what appear to be preoccupations.
In actuality, the patient is still scanning his nearly blank internal environment.
It is at this stage, however, that the depersonalization syndrome separates
into two distinct entities, with most patients remaining immobilized by the
feelings of unreality. Usually, in the patient who is a female, of low status in
education, or not inclined towards introspection, the feelings of unreality pre
dominate.
In another type of patient, one who is likely to be highly educated, male,
and already extremely prone to introspection, the feelings of unreality take a
secondary stance in favor of morbid self-preoccupation. The fuse, feelings of
unreality, sets off the explosion: metaphysical preoccupation with nothingness.
The patient is likely to dwell endlessly on the meaning of time, self, consciousness,
emotion, or moral values. Intrinsic in his arguments will likely be a strange,
winding path of hyperconsciousness, depersonalization and active, though nongenuine,
reliving of both states through memory. In this manner, layer upon
layer of symptomatology begins to build up, and will soon overshadow the feelings
of unreality which are at the root of the problem.
Finally, the patient will progressively dissect his experiences in the ultimate.
The projected attitude is one of lessening depression, decreasing anxiety, but
unfortunately, almost totally detached introspection. This metaphysical world,
in which we all inhabit different levels of reality, does not stand up to scrutiny
of the magnitude to which it is subjected by these patients. It is one thing to
question worth, yet another to constantly question why worth is needed. It is
necessary to examine one’s emotions, but emotions become unreal qualities when
subjected to such questions as, “Where is emotion received?”, or “HOW is it that
I sense any feeling at all?” and finally, “By what substrate is emotion carried
from one part of the brain to another?”, in the words of one patient whose
occupation was that of a neuroanatomist. The peculiar, and ultimately indescribably
complex tie to sanity and willed thought which contains meaning
for the individual vanishes for these unfortunate patients, as a consequence of
the above-mentioned symptomatology and the basic, never-changing feelings of
not possessing ‘Lwholeness”, “oneness”, or “feet planted firmly on the ground”,
which is the original complaint of nearly all depersonalized patients.
The veil which separates the depersonalized patient from his world now contains
so many components that it becomes nearly impossible to repair damage
which could cause depersonalization, because of the strewn wreckage of various
metaphysical remnants which the patient has in his repertoire. Depersonalization
has forced an already highly introspective character to stand back and examine
“being” itself, and all of its characteristics, most of which are inexacting and
nebulous in the extreme, even to those of us who claim rationality. Thus these
people are actually changed in two ways: They are still depersonalized, and as
a result of their neurotic state, they are faced with problems which most of us
seldom have to face (e.g. the essential absurdity of any aspect of existence when
examined for too long with too much intensity).
Even as unlikely, or perhaps ephemeral, as this syndrome is beginning to
sound, there is more than ample precedence in the literature.
Slater & Roth (1969) speak of a “primary depersonalization syndrome ... the
depersonalization does not appear to be secondary to some other psychiatric
disorder, although difficulty in establishing personal relationships and in negotiating
adolescence in general, and an abnormal degree of self-absorption, withdrawal
into fantasy or rumination about fate, time and death are common
features.”
Roberts (1960) provides several vivid eye-witness accounts of depersonalization
in a sample of college students: “There is a feeling of extreme fatigue, and an
inability to cope with or be interested in persons or things - coupled with
emotional distress at this inability ... as soon as I relax I get an intense feeling
of (‘Me” being located in my brain just behind my eyes. I am extremely aware
of myself as being alive and existing in this particular place, but the rest of
my head and body - except my eyes - does not belong to “Me”. My body is
felt as a pure biological machine automatically pumping food and air to keep
alive my brain.”
Another student reflected, “My impression was that I did this to reassure myself
- bring myself back. The most striking feeling being that I did not know
what a person was. In other words I was saying to myself, ‘I am a human
being and my name is S..., but whereas this would normally have been a
joke or a tautology because I could not imagine anything else, it here took on
significance because of having a feeling of strangeness - that is, that it could
be questioned’.”
Roberts (1960) states: “in perceptual development the non-introspected self
(the imaginer) comes to set up a self-image, using the body as a fundament, to
form an object of the body, and to complete external perception by representation
in objects ... In dp (depersonalization) there is an absence of the self-image.
The persistent need to apprehend the self, results in ceaseless and useless
self-scrutiny.”
Skoog (1965) points to numerous studies relating rather philosophical obsessions
with inadequate feelings of self and depersonalization as predecessors:
“Doubt or uncertainty is the key word even for patients with depersonalization. It
is also the patient with obsessive doubt and related anancasms who most exhibits the
feeling of unreality vis a vis the “self” and environment. The perseveration tendency
in anancasts is certainly a contributory factor: repetitive experience of general insecurity
results in a feeling of estrangement from the objects of reality - existence
is no longer so concrete, it loses substance and becomes misty and dream-like. The
feeling can gradually crystallize into brooding and doubt anancasms which, owing to
their monotony of perseveration, accentuate the insufficiency of contact with “reality”
still more ... Such connections were so common in my material that it appears difficult
to distinguish between anancasms and depersonalization. The patients experience
their unreality phenomena as shrouds d anancastic doubt - “It is as if I were not
mentally present. Do I really exist?” ... In obsessive rumination ... the anancasm
is often nothing but a monotonous, perseveratory compulsive repetition of depersonalization
symptoms manifesting themselves as subjective corpora aliene in an otherwise
adequate experience. “What is a human being?” - “What is this?” (the patient
embraces himself with his arms) - “Why me?” - “Why do just I live?” - “Why is the
wall painted green and not some other color?” - the obsessive questioning can in
principle never get any answer, never find any rest, the perseveration goes on and on,
unreality persists and the anancasms become fixated.”
III
While we see from the above descriptions that depersonalization can take on
a rather esoteric picture, possessing a focus on intellectual and rather metaphysical
questions, what seems to be present in a rather unequivocal manner
is that in nearly all cases of depersonalization, it is the obsessional nature of
the syndrome which seems to provide the drive and the “staying power” to the
syndrome.
In depersonalization, self-observation is listed as a concurrent or resultant
symptom. It is usually, rather, a primary causative factor. We have seen that the
majority of patients who experience depersonalization syndromes are quite obsessional
in personality type. Throughout the illness, most of the patients are
prone to relate the focus of anxiety to themselves, to ask the question (perhaps
even consciously), “What is wrong with me?”. As we have seen the depersonalized
patient progress from the beginning of the syndrome, these steps seem to
be present in most, if not all cases:
A. Predisposition to obsessional thinking, with high standards of self-acceptabil-
ity and almost predictable low self-esteem.
B. Doubt, uncertainty, and strong introspective features.
C. A consequential repetitive experience of insecurity.
D. Refocusing of the insecurity on the self and the self in the world, perhaps
secondary to trauma or chronic stress.
E. Obsession with the self.
F. Failure of the self to withstand such rigorous self-scrutiny.
G. Depersonalization, with depression and anxiety.
H. Exacerbation of feelings of unreality and self-estrangement.
I. Further obsessive defenses and the heightened experience of unreality.
REFERENCES
Cattell, J. P. (1966): Depersonalization phenomena. In Arieti, S. (ed.): American hand-
Davison, K. (1964): Episodic depersonalization: Observations of seven patients. Brit. J.
Dixon, I. C. (1963): Depersonalization phenomena in a sample population of college
Federn, P. (1928): Some variations in ego-feeling. Int. J. Psycho-Anal. 7, 434.
Freud,S. (1941): A disturbance of memory on the Acropolis (1936). Translated by
Lion, E. G. (1942): Anancastic depression. J. new. ment. Dis. 95, 730-738.
Nunberg, H. (1924): Uber Depersonalisations-Zustande im Lichte der Libidotheorie. Int.
Oberndorf, C. P. (1934): Depersonalization in relation to erotization of thought. Int. J.
Reik, T. (1927): Wie man Psychologe wird. Internationaler Psychoanalytischer Verlag,
Roberts, W. W. (1960): Normal and abnormal depersonalization. J. ment. Sci. 106,
Rorh, M. (1959): The phobioanxiety depersonalization syndrome. Proc. roy. SOC. Med.
Sadger, I. (1928): Uber Depersonalisatioa. Int. Z. Psychoanal. 14, 315.
Schilder, P. (1939): The treatment of depersonalization. Bull. N.Y. Acad. Med. 52,
Schilder, P. (1950): The image and appearance of the human body. International Uni-
Shorvon,H.J. (1946): The depersonalization syndrome. Proc. roy. SOC. Med. 39, 779-
Skoog, G. (1965): Onset of anancastic conditions. Acta psychiat. scand., Suppl. 184,
Slater, E., & M. Roth (1969): Clinical psychiatry. WiIIiams & Wilkins, Baltimore, p. 121.
Received December 27, 1977
book of psychiatry. Basic Books, New York, pp. 766-799.
Psychiat. 110, 505-513.
students. Brit. J. Psychiat. 109, 371-375.
Strachey, J. Int. J. Psycho-Anal. 22(2), 93-101.
Z. Psychoanal. 10, 17.
Psycho-Anal. 15, 271.
Leipzig.
478493.
52, 587-595.
587-595.
versities Press, New York, pp. 138-141.
792.
67-78.
Evan M. Torch, M.D.
Department of Psychiatry
Box 1810, Medical College of Georgia
Augusta, Georgia 30902
USA
