Depersonalisation: trauma, alexithymia, and psychodynamic therapy

Depersonalisation as a symptom remains an enigma. Even those who keep abreast of the ever-expanding psychodiagnostic lexicon may have no knowledge of what depersonalisation is. Despite this, it is the third most common psychiatric symptom after anxiety and depression.

Depersonalisation is the subjective state of feeling disconnected from oneself. By its nature, it is difficult to convey to another person who has not directly experienced it. It can last from a few seconds to years. It is often described as terrifying and profoundly debilitating.

Many people with depersonalisation also experience derealisation, which is a subjective sense of disconnection from the outside world. If depersonalisation and derealisation become chronic and disabling symptoms, an individual may meet the diagnostic threshold for depersonalisation and derealisation disorder (DDD).

What does depersonalisation feel like?

"As if” phrases are often used by those experiencing depersonalisation to convey their experience. Such phrases indicate the person's awareness that something feels to be the case even though they know it is not. This helps to distinguish experiences of depersonalisation from psychosis.

Common “as if” phrases include:

• "It's as if I don't exist."
• "It feels as if I don't have any thoughts or emotions."
• "It's as if my hands aren't mine."
• "It's as if my reflection in the mirror is of a stranger."

Acute and relational trauma as risk factors

Acute experiences of depersonalisation are considered to last for up to a few days, whereas chronic depersonalisation can last from weeks to years. Acute depersonalisation can be triggered by severe stress, sleep deprivation, and acute traumatic experiences, such as natural disasters. Cannabis is a common trigger for both acute and chronic states.

Although acute traumatic experiences can trigger longer-lasting states of depersonalisation, chronic depersonalisation is more common in experiences of prolonged and early relational trauma, particularly in childhood emotional abuse. Such abuse may thus predispose certain adults to more enduring states of depersonalisation.

The forms of emotional abuse that are predisposing factors usually have a similar flavour; they are covert and insidious. Due to this covert and insidious nature, individuals who experienced such abuse may question if anything bad happened to them or may minimise their negative experiences. One such form of emotional abuse involves a caregiver’s failure to respect a child's boundaries. Another involves the caregiver exploiting the child to bolster or regulate their own self-esteem. Stereotypes of such caregivers include the “helicopter parent” and “stage mother”. This latter form leads the child to learn to privilege the perspective of others over their subjective experience. The child reduces the perceived risk of shame, rejection, or hostility by paying close attention to others' wants.

Privileging the third-person perspective, although once protective, comes at a cost when it is no longer needed as a protective mechanism. It leads the individual to see oneself from the outside. This makes the self feel foreign to them. Four domains of selfhood are disrupted in depersonalisation: the thinking, feeling, somatic, and agent self. If any one of these four self-domains becomes disrupted, it is possible for the self to feel unreal.

Affect phobia and alexithymia

A common feature of depersonalisation is alexithymia, a difficulty in identifying, labelling, or feeling emotions. When asking someone in a dissociated or depersonalised state how they feel, it is not unusual to hear "fine" or "I don't know" as responses. When traumatic or stressful life experiences are described, there can be a deadened, monotone, and limp quality in speech tone and pace. It is likely that alexithymia functions to protect the individual from emotions that are considered, consciously or unconsciously, unbearable.

This pronounced fear of certain emotions has been termed “affect phobia”. Certain emotions may be perceived as unbearable because, at an earlier time, they would have been dangerous to express. The display of a particular emotion may have caused a parent to withdraw from or retaliate towards the child.

For example, if expressing anger results in retaliation, withdrawal, or violence, anger is then felt to be dangerous. Anger cannot be felt or expressed, as instinctively, the child has learned that it runs counter to having core developmental needs met. When certain emotions are, for good reason, felt to be dangerous, it is better to block the emotion out as this lessens the chances of it being acted upon. In childhood, this is adaptive. In adulthood, emotions once felt to be dangerous may no longer be so. This renders the cutting off of emotion as maladaptive or a defence that is no longer useful.

The alexithymia and affect phobia characteristic of depersonalisation have meaning and function. They protect the individual from feeling or knowing they have a particular emotion. Earlier, the emotion threatened the individual's survival. Cutting off from emotions is an unconscious act. It is rooted in an earlier, implicit sense of the expression of such emotions being a matter of life or death.

Psychodynamic therapy

Psychodynamic therapy is considered particularly useful for depersonalisation when alexithymia or affect phobia have become rigid and pervasive features and defences. Psychodynamic therapies that work most directly with affect phobia fall under an umbrella of treatments known as the Experiential Dynamic Therapies (EDTs). What all EDTs share is the premise that individuals respond to distressing emotions they haven’t learned to tolerate through the use of protective mechanisms, including depersonalisation, derealisation and emotional flattening.

Case studies have indicated the utility of an affect phobia-based approach in such instances. Getting in touch with previously avoided feelings, although often curative, can be deeply distressing and mobilise high levels of anxiety. Thus, treatment should proceed only after a thorough assessment of the individual’s anxiety levels and an assessment of the individual’s capacity to tolerate anxiety and other distressing emotions. Thus, alexithymia and affect phobia need to be addressed and respected for their function such that the protective mechanisms that protect the individual from their core emotions are melted rather than stripped away.

A skilled psychodynamic therapist will be attuned to fluctuations in body language, micro facial expressions, and tone of voice. Attunement to these fluctuations helps the practitioner notice moments when dissociation is triggered or increases. The context in which this happens provides the practitioner with crucial information about the nature of the underlying emotional conflicts driving the dissociation. In these moments, the practitioner and client can work together to understand what particular emotions might have been momentarily felt or blocked out of awareness. The more the client notices these moments, the more windows of opportunity there are to feel or express hitherto cut-off emotions.

This opens up a further window of opportunity for the client to learn whether experiencing these emotions is now survivable. For example, if feared anger is noticed, the client is presented with a choice to take the risk of expressing anger in words. In taking this risk, they open themselves to the chance that their anger can be talked about and thought about. The possibility is not merely that it can be talked and thought about, but that the therapist will not retaliate or withdraw. In other words, the opportunity is present to learn that the expression of anger can be survived by both parties. Not only is the anger survivable, but expressing it to another person who can respond with openness and curiosity may foster connection, intimacy, and reparation.

I have not discussed various other unconscious defences that can be involved in depersonalisation. What I have attempted to draw attention to is an affect-focused psychodynamic approach that focuses on helping individuals to identify and familiarise themselves with emotions that were previously not felt or considered intolerable.

Moreover, such an approach offers the individual the opportunity to learn through experience, and know through experience within therapy, that hitherto intolerable feelings can be tolerated and the anxiety they generate can be regulated to within manageable levels. These experiences within therapy are ones which the depersonalised individual has likely been deprived of from an early age. It offers a method of addressing and resolving both alexithymia and affect phobia, both of which are likely mechanisms in sustaining chronic states of depersonalisation.

References

Freedman, J. (2024) ‘Depersonalisation and childhood trauma: A psychodynamic perspective’. Welldoing. Available at: https://welldoing.org/article/depersonalisation-childhood-trauma-a-psychodynamic-perspecti ve

International Experiential Dynamic Therapy Association (n.d.) ‘What is EDT?’. Available at: https://www.iedta.net/what-is-edt

Ó Laoide, A., Egan, J. and Osborn, K. (2018) ‘What was once essential may become detrimental: The mediating role of depersonalization in the relationship between childhood emotional maltreatment and psychological distress in adults’, Journal of Trauma & Dissociation, 19(5), pp. 514–534. Available at: https://psycnet.apa.org/record/2018-52423-003

Simeon, D. (2022) ‘Depersonalization/derealization disorder: Psychotherapy’, UpToDate. Available at: https://medilib.ir/uptodate/show/14695

Simeon, D. (2023) ‘Depersonalization/derealization disorder: Epidemiology, clinical features, assessment, and diagnosis’, UpToDate. Available at: https://medilib.ir/uptodate/show/14695

Simeon, D. and Abugel, J. (2023) ‘Psychodynamic psychotherapy’, in Feeling Unreal: Depersonalization and the Loss of the Self. 2nd edn. Toronto: Oxford Academic, Chapter 13. Available at: https://doi.org/10.1093/oso/9780197622445.003.0013