A knowledgeable reader of this blog asks about the relationship between depersonalization and trauma. Is feeling estranged and unreal a result of the impact of an external factor? Or is depersonalization intrinsic, just developing on its own?

 At first glance the answers are two easy “yes” to both. Yes, indeed - feeling unreal often emerges in connection with external stressors. Depersonalization forums avidly discuss such stressors. And, yes, of course - feeling unreal frequently emerges as an internal experience without any connection to external factors. This is the case of Amiel, the author of the term of ‘depersonalization’, the name he gave to his own feeling of estrangement.

 However, on second thought these two easy “yes” leave unaddressed critical issues about the causality of depersonalization. What is a cause? What is a trigger? What is the difference between them? This post reflects on these issues.

 Cause versus Trigger.

 There is an urge to find a cause – the exact precise reason – of disease. This urge is rarely satisfied. Initially infectious diseases seem to demonstrate a successful model of medical causality. The discovery of microbes suggests clear cause-effect connections. A microbe is a cause and symptoms are results of this microbe’s activity. However, this reassuring scheme fails to explain clinical reality. For example, why do some people exposed to an individual with the Ebola virus not contract and others do contract the disease?

 The causality of mental diseases is to be sure a considerably more grey area. No “microbe” of depression nor “bug” of anxiety. The gene has been looked upon as a possible “mental bug.” But the gap between molecular genetics constructions and clinical situations appears insurmountable. Plus a paradoxical tendency: the more scientific achievements in brain science and social psychology, the less certainty about causality in mental illness. On the verge of the “neuroscientific revolution” the DSM III-R discards the traditional medical fundamentals of etiology, a concept that identifies illness according to its cause. The latest DSM-5, armored by the newest neuroscience discoveries, tends to avoid statements on causality and instead discusses precipitating factors.

 Precipitating Factors of Depersonalization.

The exact cause of depersonalization has not been identified. No “bug,” nor “gene.” Many neurobiological speculations exist, but a convincing hypothesis is still to be formulated. However, precipitating factors of depersonalization have been extensively and intensively explored. These factors are not absolute reasons of unreality, but agents which may contribute to the development of depersonalization. The impact of a precipitating factor may or may not be followed by unreality. The exploration of precipitating factors does not provide final clarity about the mechanisms of depersonalization, but rather facilitate understanding of the complexity of clinical reality and ambiguity of the current state of affairs in the study of depersonalization. 

 The precipitating factors can be divided into three groups: neurochemical, physical/physiological and psychosocial. The examination of the controversial causality of depersonalization begins with classic case of a freshman smoking weed.

 Neurochemical Factors.

 Neurochemical factors embrace a wide spectrum of psychoactive substances, including marijuana, hallucinogens, stimulants, ecstasy and others. On being ingested they are immediately involved in brain processes, presumably facilitating processes that lead to feeling unreal. Psychoactive substances are thought to be one of the common triggers of depersonalization.

 A college freshman experimenting with altered states of consciousness, who after smoking marijuana is seized by a severe paroxysm of unreality and anxiety, can be considered a classical case of the onset of depersonalization. This case illustrates the density of the cause-effect relationship in depersonalization. Let’s consider three following scenari to demonstrate the variety of connections between a substance and feeling unreal: from direct causality to equivocal complexity.

 The first scenario is of marijuana (or other substance) as a determining cause of depersonalization. Feeling unreal comes as a direct effect of the substance during the periods of intoxication or withdrawal and does not persist after the recovery from using the substance. Depersonalization is not a sovereign disorder, but a merely part of brain’s response to the substance. The first scenario does not meet criteria of Depersonalization Derealization Disorder (DDD), but fits the category of Substance Related Disorders.

 The second scenario is of marijuana as a precipitating factor that triggers the development of Depersonalization Derealization Disorder (DDD) persisting for years. The important characteristic is that symptoms of estrangement and unreality develop further on their own long after the initial impact of the psychoactive substance. Often patients purposely avoid the precipitating substance but this does not help to alleviate the phenomena of depersonalization originally triggered by this very substance.   

 And finally, the third scenario is of marijuana as not a determining cause nor a trigger of depersonalization, but as a sign of this freshman’s disordered well-being. This is rooted in a classic post hocpropter hoc confusion. Our deterministically set mind tends to follow “after this therefore because of this” logic. The observation that depersonalization emerges after smoking marijuana “naturally” transforms into belief that depersonalization appears because of smoking marijuana.  However, this “obvious” logic is not always confirmed by clinical reality. In a number of cases using substances is not a trigger but rather a response to primary subtle depersonalization.

Time is needed to recognize this dynamics. On the verge of acute depersonalization triggered by substances, a person is too disturbed to think through his experiences. When acuteness subsides, the person realizes that using substances was not actually “initial.” It was preceded by a “dull emptiness of my head” or a “strange inner void” for weeks or months prior to using the substance. These subtle initial elements of estrangement are not just difficult to report to others, but difficult to distinguish for oneself. The very “wish” to use substances might be an attempt to find relief from the turmoil of initial depersonalization. Unfortunately, such pseudo-treatment can open up a Pandora box of severe depersonalization. So using substances itself may come as a response to initial unreality. But then it serves as a factor that aggravates the course of disease. Subtle signs of unreality unfold into flourishing progressing symptoms. This process often results in years of chronic depersonalization.   

The physical/physiological stressors and psychosocial stressors as precipitating factors of depersonalization are discussing in the next post.

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