Depersonalization and Feelings of Unreality: Significant Symptoms With a Variety of Meanings

Evaluations and diagnostic procedures in clinical psychiatry depend mainly on how the patient communicates his or her subjective experiences and on the psychiatrist's ability to understand that message. This is critical not only for understanding and offering proper treatment, but also for developing diagnostic classifications. Hence the paper by Radovic and Radovic deals with an important topic, aiming to clarify the variety of meanings of the closely related terms unreality and depersonalization. The latter occurs as a symptom in connection to some psychiatric disorder and also constitutes a separate syndrome

I agree with the authors that the rather intense renewing of the diagnostic criteria is seldom balanced by corresponding ambitions to analyze and improve the distinctness of the words for the experiences and symptoms which define the diagnoses.It is indeed a difficult task to demarcate what should be included in the concepts feelings of unreality and depersonalization and even to decide whether they are synonyms or distinguishable. There is at least one clear agreement in the different diagnostic systems: psychotic, delusional experiences are excluded. The border between unreality feelings with largely intact reality-testing ability and psychotic disorders with grossly disturbed reality-testing is, however, not absolute and patients with psychotic disorders may of course experience feelings of unreality or depersonalization

The authors present a useful scheme by which different meanings of derealization are separated and that also points out the differences between depersonalization and derealization, although they are mutually dependant. Category (a), which come closest to depersonalization, includes experiences related to the self, whereas category (c) refers to impressions that the external world is unreal. Category (b), in their scheme, refers to altered bodily sensations: "the body part of the self" (Are there any body parts of the self? Perhaps all psychoanalysts would not agree).

In my view, this scheme is useful and corresponds to clinical realities. Symptoms belonging to category (a) can, for instance, occur in affective disorders of almost psychotic depth, due to a pathologically changed self-esteem. Symptoms belonging to category (b)—experiences of having moved outside one's own body—mainly belong to the diagnostic category dissociative disorders and can be understood as defense reactions to earlier traumatic experiences. The self escaped from the body during repeated experiences of sexual abuse. The diagnosis of depersonalization disorder consequentlybelongs to the group of dissociative disorders. Conditions where the outer world seems unreal (category [c]) can occur when the amount of internal stimuli is increased beyond what is possible to handle and therefore the capacity to recognize the environment is limited. So is the case in severe panic anxiety. Feelings of unreality as part of grief reactions may also belong, at least partly, to category (c): when dramatic and emotionally unacceptable events occur in the environment. As the authors point out, expressions of unreality feelings during grief more often can be understood as metaphors or existential reflections. In conclusion, categories -(a) and (c) can serve to separate depersonalization experiences with different psychopathologic origin, although they are closely related.

As a second step, the authors examine how the terms unreal and feels unreal can be understood. Two interpretations of unreal, "nonexistent" and "artificial," have high psychiatric relevance; a third meaning, relating to "quality," mainly has linguistic connections to the experiences on unreality and depersonalization. The word feels communicates the experience of something that appears unreal although the subject has an intact ability of reality testing.

The authors propose an additional interpretation, which they describe as a quasisensory experience. They give the example that dreams with unrealistic contents in some meaning, probably related to their intensity, appear "real." A further connection to dreams is that a situation, when awake, may have dreamlike qualities because of intensity or similarities to fragments of dreams. Events that occur in an unusual sequences, for example, corresponding to ones aims and wishes ("to good to be true") perhaps have similarities to dreamlike experiences. One may...