Depersonalization in the ER.
Man is not the only one to hide behind a mask—the mental disorder of depersonalization every so often hides itself behind the mask of a medical emergency—physical disorders that can prompt a trip to the Emergency Room. That was how I first met the syndrome of depersonalization, in my last year of medical school.
A surgeon asked me to "calm down" a boy with mild signs suggestive of appendicitis who "was panicking while awaiting surgery." Nineteen-year-old Oleg was cringing and moaning; his body trembled and his arms convulsively tightened around his abdomen. He complained of "terrible, unusual, and strange pains in my abdomen and all over my body, as if I am dying. I feel like I am dying...scared and strange."
I found myself bewildered. Surgical patients usually do not call their pain "strange." I asked Oleg, "What do you mean by 'strange'?" He became tearful, "I do not know. Everything is different...just strange. Nothing like I have ever felt before. I do not feel like myself anymore."
Gradually Oleg told his story. That evening, rushing home after an intense workout with his cross-country team, he felt "exhausted and lightheaded" and thought that he was suffering from dehydration. He drank water and tried to nap. His brother asked him something. "I looked at my brother and felt removed and disconnected, like in a fog," Oleg recalled. "I thought that I had a fever. But my temperature was normal. I had a bizarre thought that I had a mental fever. I was in a panic. I began to cry. My mom asked where I have pain. I said, 'Inside.' She was worried that it could be appendicitis and we drove to a hospital. At first I felt relieved: doctors and nurses would not let me die. But then my anxiety returned. What would I tell them? There were no words to describe my condition. I did feel pain when a physician was examining my abdomen. The diagnosis of appendicitis sounds almost reassuring: a 'normal' disease that could be cured. But what about my strange and crazy feelings? I do not know who I am anymore." Surgery was canceled.
Masks of a medical emergency are not rare for depersonalization—they occur in one of four or five cases. Three features are characteristic for these conditions. The first is that presentations of a medical emergency mask of depersonalization mainly belong to vital depersonalization. It involves vital—the most elemental, primordial level of self at which there is no differentiation between physical and psychological, bodily and mental or tactile sensations and emotional feelings. Disturbances of the vital self come as an experience of morbid ill-being with a distinctive connotation of "mental discordance." Two other types of vital disorders—anxiety and pain—almost always accompany vital depersonalization. In severe cases the depersonalization-anxiety dynamics form a vicious circle: depersonalization increases anxiety, and anxiety escalates depersonalization.
The second feature of medical emergency masks of depersonalization is significant difficulty in comprehending and communicating these experiences. A person suffers from inability to understand her condition and to explain it to others. The vital level is pre-verbal; it forms prior to the development of speech and cognition. Consequently, we do not have the vocabulary or conceptual structure to describe vital experiences. A person with acute vital depersonalization is trapped between her terrifying experience of a "vital catastrophe" and lack of verbal tools to describe this catastrophe. This often leads to the suffocating terror of a life-threatening emergency. The next step is rushing for urgent health care.
The third feature of a medical emergency mask of depersonalization is connected to the socio-cultural context. One patient depicts his vital depersonalization this way: "I know that something is badly wrong with me, but it feels so terrifyingly strange. It is beyond familiar reality, and words are helpless to picture it. The uncertainty and unreality are unbearable and almost apocalyptic." A person with vital depersonalization feels his state as an alarming medical emergency, but a "strangely different" and undescribable emergency. When we feel in trouble we know that there is at least one social institution that shall help us here and now, and no matter what: Emergency Care. Some patients rush to the ER "just to be in a safe place."
The socio-cultural context can help understand how a patient with depersonalization could be identified as a patient not with a mental, but a somatic disorder. The individual is certain that he needs urgent help. But he does not know how to report his condition, nor of what to complain. Some patients have told me that even at the edge of vital depersonalization they did not tell the ER doctor about the most troubling sensations - "feelings of unreality and an estranged self." Instead they "almost automatically" translate their "strange depersonalization experiences into what is assumed to be normal medical language." Some would talk about a headache or a heartache "just to get help." Some would logically conceptualize their bizarre signs into something medically acceptable. Vital depersonalization can be medically reframed as trouble with my head—an unusual paroxysm of migraine, or trouble with my heart—an "atypical heart attack," or trouble with my abdomen—"mild signs of appendicitis."
It is important to understand that people with depersonalization hidden behind the mask of a medical emergency are people who suffer from serious mental health issues and they do need medical and psychological help.