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A review by akemi_666
Feeling Unreal: Depersonalization Disorder and the Loss of the Self by Daphne Simeon, Jeffrey Abugel
4.0
I came into this book a bit wary as one of the authors is a psychiatrist and psychiatry has had a pretty awful history in its treatment of the neurodivergent. However, Simeon and Abugel explore depersonalisation across a range of fields, from phenomenology and literature to psychotherapy and neuroscience. None of the fields are elevated above any other. Furthermore, there's a decent amount of depth to their survey. In their chapter on psychotherapy, they explore early figures like Freud, Janet, and William James, alongside later relational figures like Bowlby, Donnel Stern, and Onno van der Hart, et al. Their chapter on neuroscience spans affect studies, trauma studies, biochemistry, and pharmacology. There's also a brutal honestly about how little the authors know about what engenders and alleviates depersonalisation, which is refreshing if you've read too many psychotherapy books claiming supremacy in their treatment methods.
This book argues that depersonalisation, though commonly experienced alongside depression and anxiety, as well as sharing symptoms with dissociative identity disorder (DID), borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD), is a distinct psychological phenomenon. As with DID, BPD, and PTSD, depersonalisation is dissociative. Following on from Janet, dissociation is understood as an adaptive biological mechanism, which may become maladaptive through intense or prolonged stress. Instead of the activation of the parasympathetic nervous system (fight, flight, freeze, or plead), a person may dissociate, retaining their capacities to deal with the situation, but from a site of phenomenological distance (out-of-body, derealised, no-self). The consequence of this is that the world / self no longer feels real. Actions feel artificial, objects signify nothing, and emotions become inaccessible. This process becomes a disorder when a person continues to feel unreal, despite a change in their circumstances. While DID, BPD, and PTSD operate through dissociation as well, in all three memories are compartmentalised (into different self-states). This is why people who have DID, BPD, or PTSD may appear like they're lying when they don't acknowledge their problematic or abusive behaviours—they may, literally, not be able to recall such behaviours. Depersonalisation, however, differs from DID, BPD, and PTSD, because it affects attention, rather than memory. Depersonalised persons don't have any issues retrieving memories, but rather, in incorporating negative stimuli and triggers into their episodic memories. They're blocked at the start of memory formation, rather than at the end.
Depersonalisation also differs from depression and anxiety, because it can last beyond depressive and anxious episodes. In other words, feelings of detachment from the world, or of oneself as an automaton or zombie, may continue even after the depersonalised person has recovered from depression or anxiety and are back into a regular schedule (school, work, socialising, so forth). In fact, it's this appearance of competence, combined with absolute listlessness, that is terrifying for the depersonalised person. They're terrified that others will find out about their condition. This reflexive terror, however, separates depersonalisation from psychosis. In psychosis, unreality is embraced. In depersonalisation, unreality is rejected as something that should not be—as something terribly wrong. For the depersonalised then, reality testing is intact, while for the psychotic, reality testing is impaired. The psychotic doesn't know that they're deluded, while the depersonalised person does.
—
It's kinda wild to me that depersonalisation was little known at the time of this book's publication. The authors lament that many depersonalised persons live in agony their whole lives, thinking they've gone insane, having no community to share their condition with, and having incompetent doctors and therapists tell them they're just experiencing depression and that such feelings will pass. I learnt about depersonalisation when I was a teen. I've experienced it, in scattered moments, throughout my life. As a kid I would derealise while watching TV. The room would stretch and the TV would seem forever away. Sometimes it'd be like I was watching TV from behind myself. I derealised during my third year at university. There were too many readings for me to keep up with. The words in front me jumbled incoherent. I went to the mall and stared at people going up an escalator. They were all staring blankly into the back of the person in front of them. Another time I had some chop and fell paralysed onto a bed. The people around me repeated the same conversation three times in a row. It felt like an eternity. When I got home I threw up.
I realise now that Lovecraft and Kafka were writing about derealisation. Lovecraft's protagonists are fixated on questions of sanity and reality. Such an ontological rupture is a moment of depersonalisation. Kafka's worlds are an eerie mix of farcical, mechanical, and oneiric. The mechanical precision of the world is often offset with comic human interactions. The world doesn't feel real, yet these situations are just as common in our world. When I tried to kill myself half a decade ago, I swallowed a bunch of pills and sat on the grass outside. A bunch of cats wandered over to me, as if they were checking in on me. Cars began arriving, one after another, slipping into driveways with clockwork timing. It was 5pm, the end of the workday. In that moment, I realised dying was as absurd as living. That no matter my actions, the world would keep going, so I might as well too.
—
Simeon and Abugel state that few, if any, of the drugs prescribed for depression, anxiety, or psychosis, affect depersonalisation. Psychotherapy, however, can lessen its intensity. Validation of depersonalisation as widespread is essential. As many depersonalised persons feel isolated and insane, connecting them to the centuries of literature detailing such experiences (from Christian mystics to Buddhists to existentialists), as well as to other people presently living through such experiences, can reduce their anxiety immensely. Orna Guralnik hypothesises that depersonalisation stems from an invalidating environment. Validation of dismissed or disregarded parts of the patient then, may lessen depersonalisation. Simeon and Abugel add that CBT daily diaries have been shown to help patients identify triggers, as well as cycles, to their depersonalisation episodes, giving them much needed control of a state experienced as totally dispossessing. They further state that it's important to differentiate between low-arousal and high-arousal patients, for those low will benefit from energising activities (like exercise), while those high will benefit with relaxing activities (like meditation).
Let's be honest, these are pretty lacklustre suggestions. They're fine, but not enough. There's a distinct lack of research from somatic therapies in this book—research that's shown how stress and trauma is held bodily, and thus bodily interventions are needed to drive psychological change. While Simeon and Abugel do mention validation as an important technique, there's little else drawn from relational, attachment, and emotion-focused psychotherapies. While I understand that Simeon and Abugel are reluctant to view depersonalisation treatments as interchangeable with those for PTSD or depression, there're plenty of therapeutic avenues they could, nonetheless, speculate on. In their chapter on neurochemistry, they explore a breadth of drugs (most of which they show do nothing). There's no reason they couldn't have explored a range of therapeutic modes in their chapter on psychotherapy. This is a solid book, but its final chapter is scant and disappointing.
What do I do if my friend is dissociating? If they no longer recognise their own hands? If they feel like life is a dream from which they can't wake except through death? What if they're so resigned to their living death that suicide itself feels ontologically impossible, because you can't kill what's already dead? I get that this isn't a community organising book, but sometimes we don't have access to therapists, let alone therapists who specialise in depersonalisation. Again, this is a great book for understanding depersonalisation, but you won't find many tools for healing those in pain.
This book argues that depersonalisation, though commonly experienced alongside depression and anxiety, as well as sharing symptoms with dissociative identity disorder (DID), borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD), is a distinct psychological phenomenon. As with DID, BPD, and PTSD, depersonalisation is dissociative. Following on from Janet, dissociation is understood as an adaptive biological mechanism, which may become maladaptive through intense or prolonged stress. Instead of the activation of the parasympathetic nervous system (fight, flight, freeze, or plead), a person may dissociate, retaining their capacities to deal with the situation, but from a site of phenomenological distance (out-of-body, derealised, no-self). The consequence of this is that the world / self no longer feels real. Actions feel artificial, objects signify nothing, and emotions become inaccessible. This process becomes a disorder when a person continues to feel unreal, despite a change in their circumstances. While DID, BPD, and PTSD operate through dissociation as well, in all three memories are compartmentalised (into different self-states). This is why people who have DID, BPD, or PTSD may appear like they're lying when they don't acknowledge their problematic or abusive behaviours—they may, literally, not be able to recall such behaviours. Depersonalisation, however, differs from DID, BPD, and PTSD, because it affects attention, rather than memory. Depersonalised persons don't have any issues retrieving memories, but rather, in incorporating negative stimuli and triggers into their episodic memories. They're blocked at the start of memory formation, rather than at the end.
Depersonalisation also differs from depression and anxiety, because it can last beyond depressive and anxious episodes. In other words, feelings of detachment from the world, or of oneself as an automaton or zombie, may continue even after the depersonalised person has recovered from depression or anxiety and are back into a regular schedule (school, work, socialising, so forth). In fact, it's this appearance of competence, combined with absolute listlessness, that is terrifying for the depersonalised person. They're terrified that others will find out about their condition. This reflexive terror, however, separates depersonalisation from psychosis. In psychosis, unreality is embraced. In depersonalisation, unreality is rejected as something that should not be—as something terribly wrong. For the depersonalised then, reality testing is intact, while for the psychotic, reality testing is impaired. The psychotic doesn't know that they're deluded, while the depersonalised person does.
—
It's kinda wild to me that depersonalisation was little known at the time of this book's publication. The authors lament that many depersonalised persons live in agony their whole lives, thinking they've gone insane, having no community to share their condition with, and having incompetent doctors and therapists tell them they're just experiencing depression and that such feelings will pass. I learnt about depersonalisation when I was a teen. I've experienced it, in scattered moments, throughout my life. As a kid I would derealise while watching TV. The room would stretch and the TV would seem forever away. Sometimes it'd be like I was watching TV from behind myself. I derealised during my third year at university. There were too many readings for me to keep up with. The words in front me jumbled incoherent. I went to the mall and stared at people going up an escalator. They were all staring blankly into the back of the person in front of them. Another time I had some chop and fell paralysed onto a bed. The people around me repeated the same conversation three times in a row. It felt like an eternity. When I got home I threw up.
I realise now that Lovecraft and Kafka were writing about derealisation. Lovecraft's protagonists are fixated on questions of sanity and reality. Such an ontological rupture is a moment of depersonalisation. Kafka's worlds are an eerie mix of farcical, mechanical, and oneiric. The mechanical precision of the world is often offset with comic human interactions. The world doesn't feel real, yet these situations are just as common in our world. When I tried to kill myself half a decade ago, I swallowed a bunch of pills and sat on the grass outside. A bunch of cats wandered over to me, as if they were checking in on me. Cars began arriving, one after another, slipping into driveways with clockwork timing. It was 5pm, the end of the workday. In that moment, I realised dying was as absurd as living. That no matter my actions, the world would keep going, so I might as well too.
—
Simeon and Abugel state that few, if any, of the drugs prescribed for depression, anxiety, or psychosis, affect depersonalisation. Psychotherapy, however, can lessen its intensity. Validation of depersonalisation as widespread is essential. As many depersonalised persons feel isolated and insane, connecting them to the centuries of literature detailing such experiences (from Christian mystics to Buddhists to existentialists), as well as to other people presently living through such experiences, can reduce their anxiety immensely. Orna Guralnik hypothesises that depersonalisation stems from an invalidating environment. Validation of dismissed or disregarded parts of the patient then, may lessen depersonalisation. Simeon and Abugel add that CBT daily diaries have been shown to help patients identify triggers, as well as cycles, to their depersonalisation episodes, giving them much needed control of a state experienced as totally dispossessing. They further state that it's important to differentiate between low-arousal and high-arousal patients, for those low will benefit from energising activities (like exercise), while those high will benefit with relaxing activities (like meditation).
Let's be honest, these are pretty lacklustre suggestions. They're fine, but not enough. There's a distinct lack of research from somatic therapies in this book—research that's shown how stress and trauma is held bodily, and thus bodily interventions are needed to drive psychological change. While Simeon and Abugel do mention validation as an important technique, there's little else drawn from relational, attachment, and emotion-focused psychotherapies. While I understand that Simeon and Abugel are reluctant to view depersonalisation treatments as interchangeable with those for PTSD or depression, there're plenty of therapeutic avenues they could, nonetheless, speculate on. In their chapter on neurochemistry, they explore a breadth of drugs (most of which they show do nothing). There's no reason they couldn't have explored a range of therapeutic modes in their chapter on psychotherapy. This is a solid book, but its final chapter is scant and disappointing.
What do I do if my friend is dissociating? If they no longer recognise their own hands? If they feel like life is a dream from which they can't wake except through death? What if they're so resigned to their living death that suicide itself feels ontologically impossible, because you can't kill what's already dead? I get that this isn't a community organising book, but sometimes we don't have access to therapists, let alone therapists who specialise in depersonalisation. Again, this is a great book for understanding depersonalisation, but you won't find many tools for healing those in pain.