The Cambridge Depersonalization Scale: a new instrument for the measurement of depersonalization

Existing self-rating scales to measure depersonalization either show dubious face validity or fail to address the phenomenological complexity of depersonalization. Based on a comprehensive study of the phenomenology of this condition, a new self-rating depersonalization questionnaire was constructed. The Cambridge Depersonalization Scale is meant to capture the frequency and duration of depersonalization symptoms over the 'last 6 months'. It has been tested on a sample of 35 patients with DSM-IV depersonalization disorder, 22 with anxiety disorders, and 20 with temporal lobe epilepsy. Scores were compared against clinical diagnoses (gold standard) and correlated with the depersonalization subscale of the Dissociation Experiences Scale (DES). The scale was able to differentiate patients with DSM-IV depersonalization disorder from the other groups, and showed specific correlations with the depersonalization subscale of the DES (r=0.80; P=0.0007). The scale also showed high internal consistency and good reliability (Cronbach alpha and split-half reliability were 0.89 and 0.92, respectively). The instrument can, therefore, be considered as valid and reliable, and can be profitably used in both clinical and neurobiological research.     

Reliability and validity of the Thai version of the WHO-Five Well-Being Index in primary care patients

Aims:  Because of the high patient load in Thailand, we need a practical measurement to help primary physicians detect depression. This study aimed to examine the reliability and validity of the Thai version of the World Health Organization-Five Well-Being Index (WHO-5-T), which is short and easy to use as a screening tool for major depression in primary care patients.
Methods:  The English version of the WHO-Five Well-Being Index was translated into Thai. Back-translations, cross-cultural adaptation and field testing of the pre-final version with final adjustments were performed accordingly. The WHO-5-T was administered randomly to 300 patients in our primary care clinic. Then the patients were further assessed using the Mini International Neuropsychiatric Interview and the Hamilton Rating Scale for Depression as the gold standard of diagnosis and symptom severity, respectively.
Results:  Completed data were obtained from 274 respondents. Their mean age was 44.6 years [standard deviation (SD) = 14.7] and 73.7% of them were female. The mean WHO-5-T score was 14.32 (SD = 5.26). The WHO-5-T had a satisfactory internal consistency (Cronbach's alpha = 0.87) and showed moderate convergent validity with the Hamilton Rating Scale for Depression (r = −0.54; P  < 0.001). The optimal cut-off score of the WHO-5-T <12 revealed a sensitivity of 0.89 and a specificity of 0.71 in detecting depression. The area under the curve in this study was 0.86 (SD = 0.03, 95% confidence interval 0.81 to 0.89).
Conclusions:  The Thai version of the WHO-Five Well-Being Index was found to be a reliable and valid self-assessment to screen for major depression in primary care setting at a cut-off point of <12.     

Dissociation in Epilepsy and Conversion Nonepileptic Seizures

Summary: Purpose: We examined the dimensionality of the item content of the Dissociative Experiences Scale (DES) in relation to the clinical diagnosis of conversion nonepileptic seizures (C-NES) versus complex partial epilepsy (CPE).
Methods : The DES was administered to a sex- and agematched sample of 132 patients with C-NES and 169 with CPE and was factor analyzed with principal components analysis (PCA) with varimax rotation.
Results : The mean total DES score was 15.1 in the C-NES group and 12.7 in the CPE group (p = 0.079). The factors obtained by PCA differentiated the CPE and C-NES groups more strongly than did the total DES score. The factor accounting for the most variance, interpreted as "depersonalizationderealization," was significantly greater in C-NES than CPE (p = 0.005). An "absorption-imaginative involvement" factor, which included some of the clinical features of posttraumatic stress disorder was elevated only in subjects reporting histories of childhood abuse (p = 0.001) regardless of the diagnosis of CPE or C-NES. An "amnestic" factor appearing to represent memory problems related to neurologic impairment showed a trend toward elevation in CPE (p = 0.056) and may have confounded the CPE versus C-NES distinction using total DES scores.
Conclusions : The DES has separate underlying dimensions that appear to relate distinctively to depersonalization and derealization, childhood trauma, and neurologic impairment. The heterogeneous item content of the DES is a potential confound that should be appreciated when this instrument is used to study dissociation in neuropsychiatric populations.     

Validation of the Chinese version of the Mood Disorder Questionnaire in a psychiatric population in Hong Kong

Aims:  The aim of the present study was to determine the validity of a Chinese version of the Mood Disorder Questionnaire (MDQ) as a screening instrument for bipolar disorder in a psychiatric outpatient population in Hong Kong.
Methods:  A total of 185 patients primarily being treated for mood disorders were asked to fill in the Chinese MDQ and supply other personal data during their scheduled clinic visit. The mean age was 43.0 years and 65.9% were female. A subsample of 102 randomly selected subjects, stratified by the MDQ symptom score, received a telephone-based Structured Clinical Interview for DSM-IV (SCID). Sixty-two patients (60.8%) were suffering from bipolar disorder (bipolar I, n  = 48; bipolar II, n  = 9; bipolar disorder not otherwise specified, n  = 5), 35 (34.3%) from depressive disorder, and one (1.0%) from substance dependence, while four (3.9%) were unaffected by either mood or alcohol/substance use disorder. The internal consistency, factor structure and operating characteristics of the Chinese MDQ were analyzed.
Results:  The internal consistency of the Chinese MDQ, evaluated using Cronbach alpha, was 0.82. Principal component analysis with varimax rotation indicated an 'energized-activity' factor and an 'irritability-racing thoughts' factor, which explained 47.2% of the rotated variance. The optimal cut-off was seven or more manic symptoms occurring within the same time period, which yielded a sensitivity of 0.73 and a specificity of 0.88 for detecting bipolar disorder. An additional criterion that the symptoms cause impairment resulted in significant loss of sensitivity.
Conclusion:  The Chinese MDQ is a valid screening instrument for bipolar disorder in a psychiatric outpatient population.     

Feeling unreal: a depersonalization disorder update of 117 cases

BACKGROUND: Despite a surge of interest and literature on depersonalization disorder in recent years, a large series of individuals with the disorder has not been described to date. In this report, we systematically elucidate the phenomenology, precipitants, antecedents, comorbidity, and treatment history in such a series. METHOD: 117 adult subjects with depersonalization disorder (DSM-III-R/DSM-IV criteria) consecutively recruited to a number of depersonalization disorder research studies were administered structured and semistructured diagnostic interviews and the Dissociative Experiences Scale. Data were gathered from 1994 to 2000. RESULTS: The illness had an approximately 1:1 gender ratio with onset around 16 years of age. The course was typically chronic and often continuous. Illness characteristics such as onset, duration, and course were not associated with symptom severity. Mood, anxiety, and personality disorders were frequently comorbid, but none predicted depersonalization severity. The most common immediate precipitants of the disorder were severe stress, depression, panic, marijuana ingestion, and hallucinogen ingestion, and none of these predicted symptom severity. Negative affects, stress, perceived threatening social interaction, and unfamiliar environments were some of the more common factors leading to symptom exacerbation. Conversely, comforting interpersonal interactions, intense emotional or physical stimulation, and relaxation tended to diminish symptom intensity. There were no significant gender differences in the clinical features of the disorder. In this sample, depersonalization tended to be refractory to various medication and psychotherapy treatments. CONCLUSION: The characteristics of depersonalization disorder found in this sample, the largest described to date, are in good accord with previous literature. The study highlights the need for novel therapeutic approaches to treat depersonalization disorder. Novel medication classes, as well as novel psychotherapeutic techniques that build on the reported symptom fluctuation factors, may prove helpful in the future.     

Autonomic response in depersonalization disorder

BACKGROUND: Emotional-processing inhibition has been suggested as a mechanism underlying some of the clinical features of depersonalization and/or derealization. In this study, we tested the prediction that autonomic response to emotional stimuli would be reduced in patients with depersonalization disorder. METHODS: The skin conductance responses of 15 patients with chronic depersonalization disorder according to DSM-IV, 15 controls, and 11 individuals with anxiety disorders according to DSM-IV, were recorded in response to nonspecific elicitors (an unexpected clap and taking a sigh) and in response to 15 randomized pictures with different emotional valences: 5 unpleasant, 5 pleasant, and 5 neutral. RESULTS: The skin conductance response to unpleasant pictures was significantly reduced in patients with depersonalization disorder (magnitude of 0.017 micro siemens in controls and 0.103 micro siemens in patients with anxiety disorders; P =.01). Also, the latency of response to these stimuli was significantly prolonged in the group with depersonalization disorder (3.01 seconds compared with 2.5 and 2.1 seconds in the control and anxiety groups, respectively; P =.02). In contrast, latency to nonspecific stimuli (clap and sigh) was significantly shorter in the depersonalization and anxiety groups (1.6 seconds) than in controls (2.3 seconds) (P =.03). CONCLUSIONS: In depersonalization disorder, autonomic response to unpleasant stimuli is reduced. The fact that patients with depersonalization disorder respond earlier to a startling noise suggests that they are in a heightened state of alertness and that the reduced response to unpleasant stimuli is caused by a selective inhibitory mechanism on emotional processing.     

The dissociative experiences of borderline patients

The study objective was to assess the severity and quality of dissociative experiences reported by borderline patients. Two hundred ninety criteria-defined borderline patients and 72 axis II controls completed the Dissociative Experiences Scale (DES), a 28-item self-report measure with demonstrated reliability and validity. Thirty-two percent of borderline patients had a low level of dissociation, 42% a moderate level, and 26% a high level similar to that reported by patients meeting criteria for posttraumatic stress disorder (PTSD) or dissociative disorders. The controls had a significantly different distribution of overall DES scores: 71% reported a low level of dissociation, 26% reported a moderate level, and only 3% reported a high level. In addition, borderline patients had a significantly higher score than the controls on 21 of 28 DES items and a significantly higher overall DES score, as well as the score on the 3 factors that have been found to underlie the DES, absorption, amnesia, and depersonalization. The results of this study suggest that the severity of dissociation experienced by borderline patients is more heterogeneous than previously reported. They also suggest that borderline patients have a wider range of dissociative experiences than are commonly recognized, including experiences of absorption and amnesia, as well as experiences of depersonalization.     

Cognitive-behavior therapy for Japanese patients with panic disorder: acute phase and one-year follow-up results

Aim:  The aim of this paper is to report the outcomes and follow-up data of our cognitive behavioral therapy program for Japanese patients with panic disorder and to examine the baseline predictors of their outcomes.
Methods:  Seventy outpatients with panic disorder with or without agoraphobia were treated with manualized group cognitive behavioral therapy.
Results:  Fourteen patients (20%) did not complete the program. Among the completers, the average Panic Disorder Severity Scale score fell from 12.8 at baseline to 7.1 post-therapy (44.7% reduction). This effectiveness was sustained for 1 year. While controlling for the baseline severity, the duration of illness and the baseline social dysfunction emerged as significant predictors of the outcome.
Conclusions:  Our data suggest that group cognitive behavioral therapy for panic disorder can bring about as much symptom reduction among Japanese patients with panic disorder as among Western patients.     

Reliability and validity of the Pervasive Developmental Disorders Assessment System

Aim:  To test the reliability and validity of the Pervasive Developmental Disorders Assessment System (PDDAS), a Japanese semistructured interview system.
Methods:  The PDDAS, consisting of 91 items including 12 major items corresponding to 12 items in criterion A of DSM-IV autistic disorder criteria, 36 items on autistic symptoms and three Asperger's disorder (AS) screening items for diagnosing pervasive developmental disorders (PDD) and their subtypes and 40 items for other information including early development and past/family histories, was administered to mothers of 77 PDD children and 64 non-PDD children.
Results:  The PDDAS had satisfactory interrater reliability (ranges of κ, r and raw agreement rate were 0.69–1.00 in 76 items, 1.00 in 11 items and 0.91–1.00 in four κ un-calculable items, respectively). Thirty-three of the 36 items and all of the 12 major items scored significantly higher in the PDD than non-PDD groups to show satisfactory discriminant validity. PDDAS and consensus DSM-IV diagnoses agreed in the 77 children in PDD diagnosis and disagreed in only two children in subtype diagnoses of autistic disorder and PDD not otherwise specified.
Conclusions:  The PDDAS, which takes 1.5 h to administer, seems to have clinical and research utility, although further investigation is necessary.     

The role of childhood interpersonal trauma in depersonalization disorder.

OBJECTIVE: In contrast to trauma's relationship with the other dissociative disorders, the relationship of trauma to depersonalization disorder is unknown. The purpose of this study was to systematically investigate the role of childhood interpersonal trauma in depersonalization disorder. METHOD: Forty-nine subjects with DSM-IV depersonalization disorder and 26 healthy comparison subjects who were free of lifetime axis I and II disorders and of comparable age and gender were administered the Dissociative Experiences Scale and the Childhood Trauma Interview, which measures separation or loss, physical neglect, emotional abuse, physical abuse, witnessing of violence, and sexual abuse. RESULTS: Childhood interpersonal trauma as a whole was highly predictive of both a diagnosis of depersonalization disorder and of scores denoting dissociation, pathological dissociation, and depersonalization. Emotional abuse, both in total score and in maximum severity, emerged as the most significant predictor both of a diagnosis of depersonalization disorder and of scores denoting depersonalization but not of general dissociation scores, which were better predicted by combined emotional and sexual abuse. The majority of the perpetrators of emotional abuse were either or both parents. Although different types of trauma were modestly correlated, only a few of these relationships were statistically significant, underscoring the importance of comprehensively considering different types of trauma in research studies. CONCLUSIONS: Childhood interpersonal trauma and, in particular, emotional abuse may play a role in the pathogenesis of depersonalization disorder. Compared to other types of childhood trauma, emotional maltreatment is a relatively neglected entity in psychiatric research and merits more attention.     

Validation of the Japanese version of the REM sleep behavior disorder questionnaire (RBDQ-JP)

BackgroundThe rapid eye movement (REM) sleep behavior disorder (RBD) questionnaire (RBDQ)-Hong Kong was the first tool developed for quantifying the severity of RBD. This study was conducted to validate the Japanese version of the questionnaire and to investigate its reliability, validity, and responsiveness.MethodsPatients with idiopathic RBD and sex and age-matched healthy controls completed the Japanese version of the questionnaire (RBDQ-JP). In addition to the evaluation of its reliability and validity, the questionnaire scores were compared between those earned before and those earned after pharmaceutical treatment to assess the questionnaire’s responsiveness.ResultsThe questionnaire demonstrated high test–retest reliability and moderate internal consistency. The best cut-off score was 19/20 with a sensitivity of 97.2% and a specificity of 97.5%. Exploratory factor analysis revealed that the questionnaire consists of the following two factors: Factor 1, Dream and dream-related behaviors and Factor 2, Violent/complex behaviors. Among the patients, significant correlation was found between the rate of change of questionnaire score and the clinical global impression improvement score with pharmaceutical treatment (rs = ?0.829, p < 0.01).ConclusionsThe RBDQ-JP provides satisfactory reliability, validity, and responsiveness. The questionnaire is suitable for severity assessment and for assessing the RBD treatment outcome.     

Scale for measuring self-recoverability in daily life for people with schizophrenia

Aim:  A new scale has been developed to assess the self-recoverability in the daily life of people with schizophrenia. Self-recoverability in daily life includes coping with stress events and taking care of one's mental and physical health. The new scale, called Self-Recoverability in Daily Life (SRDL), is a semi-structured instrument with 10 items. The aim of the present study was therefore to test the scale accordingly.
Methods:  A total of 57 subjects who were outpatients with a diagnosis of schizophrenia or schizoaffective disorder as defined by DSM-IV, were enrolled in the study. The SRDL scale was assessed with four other scales: the World Health Organization Quality Of Life (WHO-QOL)-26, the Visual Analog Scale (VAS) for health state, the Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS) and the Brief Psychiatric Rating Scale (BPRS).
Results:  The mean total score of the SRDL scale was positively correlated with both the WHO-QOL-26 and VAS, while the SRDL scale was negatively correlated with the BPRS total score.
Conclusion:  The SRDL scale may be useful for assessing living skills in the daily life of people with schizophrenia.     

Validation of a French version of the Dissociative Experiences Scale in a rape-victim population.

OBJECTIVE: To appreciate the extent and the features of dissociation in a hypothesized highly dissociated population, rape trauma victims, while assessing construct validity and internal consistency of a French version of the Dissociative Experiences Scale (DES), a simple screening instrument for dissociative symptoms. METHODS: One hundred and forty rape victims (mean age 23.6 years, 9% male) consecutively attending a Consultation for Victims of Psychological Trauma at the university hospital in Tours, France, were assessed through a French version of the 28-item self-rated DES. RESULTS: The mean score (24.1) was high, and 33% of the scores exceeded a threshold set at 30. The Principal Components Analysis of the DES ratings yielded a 3-factor solution: depersonalization-derealization, amnestic fragmentation of identity, and absorption-imaginative involvement. DES reliability was studied through computation of Cronbach's alpha coefficient (0.94). CONCLUSION: During validation of a French version of the DES, the study showed that dissociation is considerably linked to rape-trauma victim populations.     

Feeling unreal: cognitive processes in depersonalization

OBJECTIVE: Depersonalization disorder is characterized by a detachment from one's sense of self and one's surroundings that leads to considerable distress and impairment yet an intact testing of reality. Depersonalized individuals often report difficulties in perception, concentration, and memory; however, data on their cognitive profiles are lacking. METHOD: Fifteen patients with depersonalization disorder were compared to 15 matched normal comparison subjects on a comprehensive neuropsychological test battery that assessed cognitive function. RESULTS: The subjects with depersonalization disorder showed a distinct cognitive profile. They performed significantly worse than the comparison subjects on certain measures of attention, short-term visual and verbal memory, and spatial reasoning within the context of comparable intellectual abilities. CONCLUSIONS: The authors propose that depersonalization involves alterations in the attentional and perceptual systems, specifically in the ability to effortfully control the focus of attention. These early encoding deficits are hypothesized to have a deleterious effect on the short-term memory system; they manifest as deficits in the ability to take in new information but not in the ability to conceptualize and manipulate previously encoded information.     

A study of the discriminative validity of a screening tool (MINI-SPIN) for social anxiety disorder applied to Brazilian university students.

OBJECTIVE: This study aimed to evaluate the discriminative validity of MINI-SPIN (MS) as a screening tool for social anxiety disorder (SAD) in a group of Brazilian university students. METHOD: SPIN was collectively applied to 2320 university students. Among them, 656 individuals who fulfilled the criteria for positive MS (N=473) and negative MS (N=183) were selected and divided into two groups. The selected subjects were interviewed by telephone using the SAD module of the SCID-IV, used as the gold standard. In order to check interrater reliability, a group of university students (N=57) was reinterviewed by telephone by a second rater, and another group (N=100) participated in a face-to-face interview. RESULTS: The Kappa coefficient among the telephone interviews was 0.80, and a coefficient of 0.84 (P<0.001) was obtained between the telephone interview and the face-to-face one. For a cut-off score of 6, suggested in the original English version of the instrument, sensitivity was 0.94, specificity 0.46, the positive predictive value (PPV) was 0.58, and the negative predictive value (NPV) was 0.92. For a cut-off score of 7, we observed an increase in the specificity and in the PPV (0.68 and 0.65) while the sensitivity and NPV (0.78 and 0.80) remained high. DISCUSSION/CONCLUSION: MS showed quite satisfactory psychometric qualities. The cut-off score of 6 seemed to be the most suitable to attest the tracking value of the tool. However, the cut-off score of 7 was the most suitable as a minimum parameter for the studied group, with psychometric values more similar to those of the original study.     

Practice-based depression screening for psychiatry outpatients: Feasibility comparison of two-types of Center for Epidemiologic Studies Depression Scales

Aims:  The Center for Epidemiologic Studies Depression Scale (CES-D) has been validated to avoid misdiagnoses of major depression in routine psychiatric outpatient settings, but it was reported to be only marginally feasible in these specific settings. A briefer and simpler version, known as the 10-item CES-D, meant to attain adequate feasibility, has been validated in geriatric outpatient settings, but it has not yet been examined in psychiatry outpatient settings. The purpose of the present study was therefore to compare the feasibility, reliability, and validity of the two types of CES-D.
Methods:  A cross-sectional analysis was conducted of 86 consecutive outpatients in a psychiatric department in a general hospital.
Results:  The 10-item CES-D has a higher feasibility than the 20-item CES-D, and its internal consistency, reliability, and validity are almost identical to those of the 20-item CES-D.
Conclusions:  The 10-item CES-D is the better instrument to use because of the higher feasibility than the 20-item CES-D in psychiatric outpatient settings. The different answer format used in each questionnaire (a yes or no format in the former vs a multiple-choice format in the latter) may influence the feasibility, rather than the number of items.     

Feeling unreal: a PET study of depersonalization disorder

OBJECTIVE: The goal of this study was to assess brain glucose metabolism and its relationship to dissociation measures and clinical symptoms in DSM-IV depersonalization disorder. METHOD: Positron emission tomography scans coregistered with magnetic resonance images of eight subjects with depersonalization disorder were compared to those of 24 healthy comparison subjects. The two groups did not differ in age, sex, education, performance on a baseline neuropsychological battery, or performance on a verbal learning task administered during [(18)F]fluorodeoxyglucose uptake. A cortical analysis by individual Brodmann's areas was performed. RESULTS: Compared to the healthy subjects, subjects with depersonalization disorder showed significantly lower metabolic activity in right Brodmann's areas 22 and 21 of the superior and middle temporal gyri and had significantly higher metabolism in parietal Brodmann's areas 7B and 39 and left occipital Brodmann's area 19. Dissociation and depersonalization scores among the subjects with depersonalization disorder were significantly positively correlated with metabolic activity in area 7B. CONCLUSIONS: Depersonalization appears to be associated with functional abnormalities along sequential hierarchical areas, secondary and cross-modal, of the sensory cortex (visual, auditory, and somatosensory), as well as areas responsible for an integrated body schema. These findings are in good agreement with the phenomenological conceptualization of depersonalization as a dissociation of perceptions as well as with the subjective symptoms of depersonalization disorder.     

The relationship of akathisia with suicidality and depersonalization among patients with schizophrenia

An association of suicidality and depersonalization with akathisia has been reported, but it is not clear whether these phenomena are specific to akathisia or are nonspecific manifestations of distress. The authors used the Barnes Akathisia Rating Scale, Brief Psychiatric Rating Scale, and Hamilton Rating Scale for Depression (Ham-D) to examine the relationships between suicidality, depersonalization, dysphoria, and akathisia in 68 patients with schizophrenia or schizophreniform disorder. Akathisia was associated with higher scores on the Ham-D ratings of suicidality, depersonalization, and agitation. In a logistic regression model, depressive mood and subjective awareness of akathisia appeared to be the only predictors of suicidality and depersonalization, respectively. These findings support the association between akathisia and both suicidality and depersonalization. However, these symptoms appear to be nonspecific responses to accompanying depressive mood and the subjective awareness of the akathisia syndrome, respectively.