Dr. Anders* felt frightened of Tony* from the very first time she met him. Fear was the least prevalent feeling that this well-seasoned psychiatrist experienced when dealing with patients. However, something about the tall, emaciated, 42-year-old was unsettling. He shuffled into her small, private office like a much older man would. Dr. Anders directed him to sit in the comfortable, black leather chair across from her. After slowly removing his charcoal-colored, tweed jacket that was too large for him, he sat down on the edge of the chair. He reeked of cigarettes. Dr Anders searched for and found the telltale sign of a yellow thumb and forefinger, which indicated a penchant for chain-smoking unfiltered cigarettes.
"I can't take it anymore, doctor. You must help me," he pleaded. His face surrounded by long, straight, brown hair was finely sculpted like Michelangelo's David. His heavy-lidded, blue eyes looked sad.
"Take your time and tell me what's wrong," she encouraged. What was it that was so disturbing about his presence, she wondered, as she felt her own heart beating rapidly as they talked?
"I've been this way for over 20 years. I don't have much hope. You're the fifth psychiatrist I've seen. No one knows how to help me," he said. Stress strained his already raspy voice and made it climb up a notch higher. It was a bad sign that she was the fifth psychiatrist. His condition sounded chronic and entrenched.
Tony told his story of being an only child whose doting mother died when he was only 10. His father, a Vet freshly returned from the Vietnam War, had raised him with the help of Tony's aunt. He'd always been anxious and a loner. In school, he'd done mediocre work. After a year of college he dropped out and married a girlfriend from high school. Then, his problem started.
"One day I was walking around the city, minding my own business, when suddenly I found myself looking down at myself from somewhere near the awning of a store. It was unreal and the weirdest thing in the world!" he exclaimed, his hands shaking. "Since then, and that was 20 years ago, I've had one experience like that after another and never completely felt like I was back in my body. I constantly feel spaced out."
Clearly, Tony was terrified of his experience. It was Tony's sense of an absence of himself that frightened Dr. Anders, not his presence, which she had assumed at first.
Tony denied any drug use. He claimed he was too scared to try anything. Dr. Anders thought he looked like a junkie or pothead, but later when she took blood and urine samples, she found that he was perfectly clean and free of drugs.
He had separated from his wife, who said she was tired of dealing with his constant complaints of being "spaced out." They still called each other and had phone sex once per week, since neither could stand to deal with the other in person. Tony was on SSI and lived in a poor Brooklyn neighborhood. He spent his days sitting indoors, smoking two packs of cigarettes per day and brooding about his condition.
He wanted Dr. Anders to refill a prescription he had taken twice daily for over 10 years. She told him she would help by giving him an antidepressant as well. He took the two prescriptions, but when he returned the following week, Dr. Anders learned that he hadn't filled his prescription for the antidepressant. He had just continued with the first medication, an addictive tranquilizer.
Their sessions went on like this for several months. Dr. Anders would prescribe an antidepressant, or an antipsychotic, or a mood stabilizer. Tony would agree to try the new medicine since he "most certainly desired" to be helped, but inevitably he would only take the one. Tony had done exactly the same thing with his previous four psychiatrists. He explained his behavior with the claim that he was too fearful to try anything new.
During psychotherapy sessions, Tony spoke about his condition and how horrible it was to feel so unreal and outside of himself. He rarely was relieved of this feeling. Medication helped only slightly. He never had any hallucinations or delusions, panic attacks or depressive episodes except relating to his condition.
Dr. Anders sent him to a neurologist who ruled out epilepsy, migraine headaches, brain tumors, Huntington's disease and any other neurological condition with a physical exam, CT scan and MRI. After an internist concluded that Tony did not have any toxic or metabolic disorders, like hypothyroidism or hypoglycemia, Dr. Anders made a diagnosis of depersonalization disorder. Tony worked with her for several more months, never taking any medicine other than the tranquilizer. He dropped out of treatment without improving. Dr. Anders felt she could have helped Tony if only he would have tried one of the new medications.
Depersonalization disorder is a "persistent or recurrent experience of feeling detached from, and as if one is an outside observer of, one's mental processes or body," according to DSMIV-TR. Reality testing remains intact. "Depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." Depersonalization does not occur exclusively during the course of another mental disorder, such as schizophrenia. It is thought that women have the disorder twice as frequently as men and that depersonalization is rarely found in those over 40. Tony clearly fit the criteria of DSMIV-TR and yet he was exceptional, being male and over 40.
Depersonalization may occur occasionally in any individual, but if it continues as it did in Tony, then it is pathological and debilitating. Tony felt like he was in a dream all the time.
Derealization is the feeling that objects around one are unreal and strange, rather than just one's body in depersonalization. Tony had derealization sometimes, but his main problem was depersonalization. Many drugs, (e.g., alcohol, barbiturates, benzodiazepines, marijuana, heroin, etc.) may induce this condition.
The disorder can occur suddenly and then be chronic. As in Tony's case, it is likely to start between the ages of 15 to 30. It is believed that it almost never begins after 30 or in the later years of life. It can be long-lasting and either steady or episodic. Unfortunately, not much is known about the treatment of depersonalization disorder. Dr. Anders' suggestions to Tony about trying various antidepressants, mood stabilizers and antipsychotics were logical, but thus far insufficient data about what really works is available.
*Not this person's real name.
Carol W. Berman, M.D. is a writer, psychiatrist and artist who lives and works in New York City. When she's not listening to patients, she's writing or painting. As an undergraduate she attended the University of California at Berkeley; she went to medical school at NYU Medical Center. Presently she is an Assistant Clinical Professor at NYU. She has practiced psychiatry for 25 years and is a member of the APA, ASJA and NWU. Her two books, "100 Questions and Answers About Panic Disorder" and "Personality Disorders," have helped thousands of patients deal with mental disorders. Read her blog on Red Room.