Depersonalization is a difficult to define “feeling unreal.” To be counted as a disorder that can be diagnosed and accordingly subject to a treatment protocol, depersonalization needs to be clearly defined by the Diagnostic and Statistical Manual of Mental Disorders. A new – fifth - edition of this manual that has just been officially approved for using in mental health practice as of October 1st 2013 is quite a fervent example of how complex and controversial is the very task of developing systematic classification of mental disorders. Widely and ardently criticized, the DSM-5 has raised a battery of sad or sarcastic comments. “Remember the old famous query: is mental health care science or art? A new classification suggests: it is industry.” This sarcasm bears the measure of reality: the DSM-5 provides a common language to bridge the pharmaceutical industry, the insurance industry, the medical hi-tech industry, the marketing industry and – yes, not-to-be-forgotten, – the clinical domain itself: mental health care providers with their skills, and patients with their disorders. The DSM-5, following in the footsteps of its four predecessors, remains a socially and politically shaped compromise between clinical practice and industry, as well as between aspirations to present the study of mental disorders as an objective, measurable and evidence-based system of hard science and the reality of mental pathology as a rather cloudy gray area with only a few explanatory models but a plentitude of subjective impressions and notoriously uncertain outcomes.
Nevertheless, whether one sees the DSM-5 as an achievement or a failure, the Manual constitutes a major document with which to organize the conceptualization of mental disorders and regulate mental health practice for years to come. The Manual brings some new elements into the formalization of depersonalization. To better understand the DSM-5 treatment of feeling unreal, it is helpful to look at it from the perspective of the development of the conceptualization of depersonalization throughout all DSMs.
The first American classification of mental disorders, the DSM-I, published in 1952, does not list depersonalization. And not just depersonalization. Many mental disorders that had been well known for ages, are absent in the first American nomenclature of psychic pathology. The DSM-I mainly represents what was then considered revolutionary, but soon after reconsidered as peculiar: the psychobiological view of Adolf Meyer and his doctrine of ergasias – mental disorders as biological reactions to psychological stressors. It takes 16 years to return from Meyerian ergasias to classical clinical psychiatry.
The next classification, the DSM-II, published in 1968, reestablishes the traditional principles of categorization of mental pathology. The DSM-II introduces depersonalization as Depersonalization Neurosis. It is defined as feelings of unreality and estrangement from the self, body or surroundings. One of its main characteristics, as typical for neuroses in general, is its psychogenic aetiology: depersonalization develops in response to psychological trauma.
Another 12 years later, in 1980, the third edition of the classification – the DSM-III - changes the categorization of depersonalization. Depersonalization is no longer a specific neurosis. It becomes Dissociative Disorder. Its taxonomic place in the class of Dissociative Disorders, depersonalization has kept ever since. So, what is dissociation, what are dissociation disorders and what is the connection between them and depersonalization? Dissociation is a complex phenomenon that is usually referred to as a disruption in the consistency and integrity of psychic experiences. Two factors contribute to the development of dissociation: personality and trauma.
First, let’s consider the personality factor. A person can experience dissociation without any evident causes. It can be felt as a personality trait – a connotation of somewhat uncertain ambiguity, a feeling of incompleteness that accompanies every presentation of psychic life. These observations give rise to the interpretation that a tendency to develop dissociation is a specific characteristic of a person. However, dissociation frequently appears to be a reaction to a psychological stressor. This leads to the second factor, trauma as a reason for dissociation. And, of course, there are varieties of approaches considering combinations of a personality factor and a trauma factor in the development of dissociation. However, personality – trauma divergence plays a certain role in understanding the journey of depersonalization through the taxons of DSMs.
Personality-factor based understanding of dissociation stems from Janet who probably should be considered the originator of the very idea of dissociation. Janet also contributes significantly to the study of depersonalization. Janet treats dissociation as more related to the mental and emotional constitution of a person. The typical portrait of Janet’s person with depersonalization is an anxious, sensitive, full of doubts, prone to overdeveloped self-analysis, somewhat obsessive and hypochondriacal introvert. Depersonalization comes as the personality pattern to relate to oneself and the world around. Psychological trauma matters, but rather as a secondary factor which “releases” inner potentials for the experiences of depersonalization. Janet’s conceptualization of dissociation remains largely off the focus of the DSMs.
Trauma-factor based understanding of dissociation stems from Freud who considers dissociation in the frame of his theory of psychological defenses which are protective responses to psychological trauma. The post WW2 triumph of the Freudian theory of dissociation in American psychiatry paves the way for DSM’s treatment of dissociation as psychological defense. Freud’s own experiences of depersonalization - that happened in a new challenging and emotionally laden atmosphere while he was visiting the Acropolis in Athens - also correspond to his theory of dissociation. The DSMs closely adhere to the Freudian defensive paradigm of dissociation. Trauma is experienced by an individual with one or another personality type. As Freud’s study of trauma is mainly based on clinical cases of hysteria, the DSMs’ original dissociation disorders are consistent with classical psychogenic hysterical reactions: dissociation of consciousness, memory and personal identity. But then, in 1980, a non-hysterical disorder of depersonalization is added to this group of hysterical conditions.
Now, let’s see what are those conditions and what is their journey inside of the DSMs? Rejecting “old” psychiatric concepts, the DSM-I naturally rejects the term hysterical neurosis, introducing instead a progressive term of dissociative ergasias (reactions). The next more traditional DSM-II re-establishes hysterical neurosis with its two subtypes: dissociative and conversion. The DSM-III not only once more eliminates the term “neurosis,” but also makes another step forward, abolishing the term “hysteria” as hopelessly out-dated. In addition, the DSM-III separates two major clusters of hysterical presentations, namely, dissociative and conversion disorders. Dissociative disorders form an independent class that embraces on the one hand the phenomena traditionally known as classical psychogenic hysterical and on the other hand depersonalization.
The subsequent DSM-IV, published in 1994, keeps depersonalization in the same class of Dissociative Disorder and does not change the definition of depersonalization or its diagnostic criteria. But the newly born DSM-5 does modify both the definition and the diagnostic criteria, and even renovate the name for the “feeling unreal.” This is to be discussed in the next post.