Elsevier

Psychiatry Research

Volume 188, Issue 2, 30 July 2011, Pages 264-268
Psychiatry Research

Distinctiveness and overlap of depersonalization with anxiety and depression in a community sample: Results from the Gutenberg Heart Study

https://doi.org/10.1016/j.psychres.2010.11.004Get rights and content

Abstract

Depersonalization disorder is considered to be a common clinical phenomenon and disorder with an enormous gap between prevalence and detection partly due to the common interpretation of depersonalization (DP) being a negligible variant of anxiety and depression. Therefore, we sought to analyze (1) the prevalence rate of DP in a large community sample (n = 5000) according to a recently developed ultra brief two-item depersonalization screener; (2) the associations with depression, anxiety, physical and mental health status; and 93) whether DP contributes independently to the health status beyond anxiety and depression. The prevalence of clinically significant DP was 0.8% (n = 41), and 8.5% (n = 427) endorsed at least one symptom of DP. DP was independently associated with impairment of mental and physical health status as well as with a medical history of any depressive or anxiety disorder. Despite the consistent association of DP with anxiety and depression, the shared variances were small, and DP was clearly separated from symptoms of anxiety and depression in the principal component analysis. Therefore, we conclude that the implementation of depersonalization screening might be recommended.

Introduction

After anxiety and depression, depersonalization has been considered to be the third most frequent symptom among psychiatric patients (Stewart, 1964). But although depersonalization (DP) is assessed routinely as part of the mental state examination in psychiatric and psychotherapeutic treatment, it is both underdetected and underdiagnosed (Simeon, 2004, Michal and Beutel, 2009, Sierra, 2009, Stein and Simeon, 2009). According to a recent evaluation of health insurance data of 1.5 million persons, the 1-year prevalence of the diagnosis of the depersonalization–derealization syndrome was only 0.007% (Michal et al., 2010a, Michal et al., 2010b, Michal et al., 2010c). This prevalence contrasts sharply with epidemiological studies reporting rates of 0.8–2% for clinically significant DP in the general population (Hunter et al., 2004, Michal et al., 2009). Reluctance of patients to report spontaneously about DP is one factor; another factor is the health care providers' relative lack of awareness, due to the common interpretation of DP as a negligible variant of anxiety and depression (Simeon, 2004, Sierra, 2009). This neglect of DP however, may also have an impact on the treatment and outcome of depression and anxiety disorders. Several studies found that DP co-occurring with depression and anxiety is an index of disease severity, chronicity and poor treatment response (Katerndahl, 2000, Mula et al., 2007). Recently, we have shown in a large community sample that depersonalization severity was independently associated with suicidal ideation beyond depression and anxiety (Michal et al., 2010b).

In order to overcome the lack of awareness for DP, questionnaires or structured interviews are extremely helpful (Edwards and Angus, 1972). For clinical and neurobiological research purposes, Sierra and Berrios (2000) developed the Cambridge Depersonalization Scale (CDS), measuring the complex phenomenology of depersonalization and derealization experiences comprehensively with 29 items (Sierra and Berrios, 2000). This scale is currently the most detailed and valid measure describing and quantifying depersonalization and derealization, but the CDS seems too costly for routine screening purposes. Therefore an ultra-brief two-item scale for DP was developed from the CDS, i.e., the two-item version of the Cambridge Depersonalization Scale (CDS-2, Michal et al., 2010c). The scoring format of the CDS-2 was adopted from the most common ultra-brief screeners for depression and anxiety (PHQ-2, Löwe et al., 2005; and GAD-2, Löwe et al., 2009) in order to establish an easy and brief screening for DP.

Against this background the present study analyzes data from a large community sample of n = 5000 participants to examine the following research questions:

  • 1)

    What is the current prevalence rate of DP in a large community sample according to the CDS-2 and how is DP related to depression and anxiety symptoms according to ultra-brief screeners and the respective medical histories?

  • 2)

    Can DP be differentiated from anxiety and depression, and does DP have an independent effect on the subjective physical and mental health status in the community?

Answers to these questions will help to determine whether DP contributes to the health status beyond anxiety and depression, and thus might ascertain the potential value of implementing the CDS-2 in routine screening procedures.

Section snippets

Study sample

The sample comprises cross-sectional data of the first n = 5000 participants enrolled in the Gutenberg Heart Study (GHS) from April 2007 to October 2008. The GHS is a community-based, prospective, observational single-center cohort study focusing cardiovascular disease in the Rhein-Main-Region in western Mid-Germany (Michal et al., 2010b). The GHS has been approved by the local ethics committee and by the local and federal data safety commissioners. The sample was drawn randomly from the local

Characteristics of the sample stratified by CDS-2  3

A percentage of 0.8% (0.6–1.1) of the participants scored in the range of clinically significant DP (CDS-2  3, DP group). Subjects with clinically significant DP were less likely to live in a current partnership, were more affected by depression and anxiety, and endorsed a poorer physical and mental health status. With respect to sociodemographic characteristics, no differences regarding age, sex, education or SES emerged (Table 1).

Distribution of the items and scores of the CDS-2 in the sample

Item 1 of the CDS-2 was endorsed at least with “several days” by

Discussion

With respect to the prevalence of DP the current study demonstrates further evidence that DP is common in the general population of Germany. However, compared to previous studies the prevalence rate of 0.8% for clinically significant DP was only in the lower range of previous studies (Hunter et al., 2004). For example, in another recent survey we found a prevalence of 3.4% in the general population for clinically significant DP by using the CD2-2 (Michal et al., 2011), and with another abridged

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