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- Martin H. Teicher, M.D. - |
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I am not a neurologist, psychiatrist, or research scientist. The following theory comes from reading about mental illness, exchanging ideas with others who experience DP, and speaking with my psychiatrists and therapists. As a N.A.M.I. consumer member, I have had the opportunity to interact with other consumers of mental health care, advocates for the mentally ill (including parents, adult children, and siblings), and other mental health care professionals.
My deepest understanding of dissociation, anxiety, and depression comes from personal experience. Unless someone has experienced true chronic DP, he or she cannot understand it -- even the most empathetic and knowledgeable physician or individual. Even severe anxiety and depression are frequently misunderstood by the population at large as "laziness or weakness of character." I believe there are complex processes in understanding mental illness or any medical disorder, and many of these questions have not been answered by the medical community. I am simply trying to understand what events have resulted in the biochemical or morphological changes in my brain that express themselves in the symptoms of my mental illness. I realize the understanding I have now can change at any time. Please remember this is not a definitive explanation of why I am ill. It reflects my interpretation (as a layperson, as of this date) of much complicated information. And again, this only reflects MY particular experience. We are all unique!
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The "Diathesis-Stress Model"
best explains the the development and evolution of my illness, and can be witnessed in the development of both psychiatric and physical pathology.
End result = illness/dysfunction with varying degrees of severity, or no illness at all. (Nature can override environmental stress or there is a high degree of inherent resilience.) |
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There are many permutations of the diathesis-stress model. I will give an example of a physical disease - lung cancer, and an analysis of my mental illness.
In the case of lung cancer, I define the "stressor" as smoking. In the case of my mental illness, the "stressor" is a severely dysfunctional upbringing.
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All I know from this model is that I very well may have been born with anxiety and a nature to dissociate and would have developed my illness regardless of my chaotic upbringing. However there is a mountain of evidence that we can't eliminate environmental factors in medical or psychiatric pathology. At minimum, I was born with an anxious nature, and was not resilient enough to cope with my constantly stressful environment. This could explain the development of many disorders that seem to "come out of the blue." There are of course a myriad of other factors. With smoking, one could consider second-hand smoke, pollution, et. al. And in terms of treatment, control and cure of any illness, that is likewise tied to the inherent nature of the individual including many other factors such as an excellent support system, religious faith, et. al. One must also consider inheriting mental illness from one's parents. Both of my parents were mentally ill as are members of my extended family. |
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And so, what is Depersonalization and Derealization in my experience? I believe it is an extension of the Fight/Flight response as succinctly delineated by V.S. Ramachandran, M.D.'s theories (see below). I have done a tremendous amount of research over the years on depersonalization and other altered states of consciousness. In my case, this makes the most sense -- that this is "secondary" to severe chronic Generalized Anxiety Disorder. And this perceptual distortion which is experienced by healthy individuals in times of severe stress could be a permanent state of Fight/Flight mode I am trapped in. There is also a great debate over "Primary Depersonalization Disorder" and depersonalization which is secondary to other illnesses. To be honest, particularly because my depersonalization has really been life-long (in various incarnations), as have my anxiety and depression, I sometimes see the DP as an illness, or "pathological state" in and of itself -- a severe perceptual distortion that can only be some sort of neurological malfunction. This seems to be the case in certain patients, but I believe that true Depersonalization Disorder is rare -- (DPD without any accompanying symptoms such as anxiety, panic, depression, etc.) Though I can't tell you which came first, my sense is that I always had a propensity to be anxious and to dissociate in times of stress, and was exposed to years of unremitting stress, chaos and verbal abuse. My predisposition was reinforced and/or exacerbated by my environment. Yet of all the symptoms I have experienced over the years, the perceptual distortions of Depersonalization and Derealization have the most serious, the most horrifying, the most limiting, the most debilitating. Again, I am angry that I never received help early in my life. Even if I was born with these predispositions, I think I could have been helped by Behavioral Therapy, Talk Therapy, medications, encouragement, and comfort. |
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| Consider the following research findings. I find these speak to my situation. But, note that medical research changes daily. What is published today, is "out of date" tomorrow. Each bit of research in neurology and psychology will lead us closer to understanding the mind, but I don't know if we can ever fully understand such a complex organ or fully understand how we have a conscious perception of "Self." |
| In quoting the authors below I have taken the liberty of emphasizing certain portions of the text; this includes highlighting, underlining, and the use of italics. |
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Update on the Neurobiology of Depression
Noah Side, M.D., Charles B. Nemeroff, M.D., MedScape CME August, 2000
"Early life trauma may result in long-term, if not permanent, hyperactivity of the CNS (Central Nervous System), CRF (corticotropin-releasing factor), and NE (norepinephrine) systems with consequent detrimental neurotoxic effects on the hippocampus that lead to decreased hippocampal volume.
These changes represent sensitization of the CRF circuits to even mild stress in adulthood, leading to an exaggerated stress response ... Upon exposure to persistent or repetitive stress in adulthood, these already-sensitive stress pathways become markedly hyperactive leading to an increase in CRF and cortisol secretion, which causes alterations in the receptors and thus forms the basis for the development of mood and anxiety disorders."
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Brain Abnormalities Common in Survivors of Childhood Abuse
Martin H. Teicher, M.D., McLean Hospital, Belmont, Massachusetts Cerebrum 2000;2:50-67. "Early abuse molds the brain to be more irritable, impulsive, suspicious, and prone to be swamped by fight-or-flight reactions that the rational mind may be unable to control....To a brain so tuned, Eden itself would seem to hold its share of dangers." |
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| The following book is required reading for anyone who wants to understand the complexity of the brain and how we process and interpret incoming and internal stimuli. |
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A Brief Tour of Human Consciousness
V.S. Ramachandran, M.D., Ph.D. Pi Press 2004, Pages 90-93.
Dr. Ramachandran from his BBC Reich Lecture:
"I'd now like to remind you of a syndrome we discussed in my first lecture, the Capgras delusion. So, the patient has been in a head injury, say a car accident. He seems quite normal in most respects, neurologically intact, but suddenly starts saying his mother is an impostor. She's some other woman pretending to be my mother. Now why would this happen, especially after a head injury? Now remember, he's quite normal in all other respects.
Well, it turns out in this patient the wire that goes from the visual areas to the emotional core of the brain, the limbic system and the amygdala, that's been cut by the accident. So he looks at the mother and since the visual areas in the brain concerned with recognizing faces is not damaged, he says, Hey it looks just like my mother. But then there is no emotion because that wire taking that information to the emotional centers is cut. So he says, If this is my mother how come I don't experience any emotions? This must be some other strange woman. She's an impostor. Well, how do you test this?
It turns out you can measure the gut-level emotional reaction that someone has to a visual stimulus - or any stimulus - by measuring the extent to which they sweat. Believe it or not, all of you here - if I show you something exciting, emotionally important, you start sweating to dissipate the heat that you're going to generate from exercise, from action. And I can measure the sweating by putting two electrodes in your skin, changes in skin resistance - and if skin resistance falls, this is called the Galvanic Skin Response. So every time anyone of you here looks at tables and chairs, there's no Galvanic Skin Response because you don't get emotionally aroused if you look at a table or a chair. If you look at strangers there's no Galvanic Skin Response. But if you look at lions and tigers and - as it turns out - if you look at your mother, you get a huge, big Galvanic Skin Response. And you don't have to be Jewish, either. Anybody here, looking at your mother, you get a huge, big Galvanic Skin Response when you look at your mother.
Well, what happens to the patient? We've tried this on patients. The patient looks at chairs and tables, nothing happens. But then we show him a picture of his mother on the screen, no Galvanic Skin Response. It's flat - supporting our idea that there's been a disconnection between vision and emotion.
Now the Capgras delusion is bizarre enough, but I'll tell you about an even more bizarre disorder. This is called the Cotard's syndrome, in which the patient starts claiming he is dead. I suggested that this is a bit like Capgras except that instead of vision alone being disconnected from the emotional centers in the brain, all the senses, everything, gets disconnected from the emotional centers. So that nothing he looks at in the world makes any sense, has any emotional significance to this person, whether he sees it or touches it or looks at it. Nothing has any emotional impact. And the only way this patient can interpret this complete emotional desolation is to say, Oh, I'm dead, doctor. However bizarre it seems to you, it's the only interpretation that makes sense to him.
Now Capgras and Cotard are both rare syndromes. But there's another disorder, a sort of mini-Cotard's that's much more commonly seen in clinical practice ... It's called Derealisation and Depersonalisation. It's seen in acute anxiety, panic attacks, depression and other dissociative states. Suddenly the world seems completely unreal - like a dream. Or you may feel that you are not real - Doctor, I feel like a zombie. Why does this happen? As I said, it's quite common.
I think it involves the same circuits as Capgras and Cotard's. You've all heard of the phrase, playing possum. An opossum when chased by a predator suddenly loses all muscle tone and plays dead. Why? This is because any movement by the possum will encourage the predatory behaviour of the carnivore - and carnivores also avoid dead infected food. So playing dead is very adaptive for the possum.
Following the lead of Martin Roth and Sierra and Berrios, I suggested Derealisation and Depersonalisation and other dissociative states are an example of playing possum in the emotional realm. And I'll explain. It's an evolutionary adaptive mechanism. Remember the story of Livingstone being mauled by a lion.
He saw his arm being ripped off but felt no pain or even fear. He felt like he was detached from it all, watching it all happen. The same thing happens, by the way, to soldiers in battle or sometimes even to women being raped. During such dire emergencies, the anterior cingular in the brain, part of the frontal lobes, becomes extremely active. This inhibits or temporarily shuts down your amygdala and other limbic emotional centers, so you suppress potentially disabling emotions like anxiety and fear - temporarily. But at the same time, the anterior cingular makes you extremely alert and vigilant so you can take the appropriate action.
Now of course in an emergency this combination of shutting down emotions and being hyper-vigilant at the same time is useful, keeping you out of harm's way. It's best to do nothing than engage in some sort of erratic behaviour. But what if the same mechanism is accidentally triggered by chemical imbalances or brain disease, when there is no emergency. You look at the world, you're intensely alert, hyper-vigilant, but it's completely devoid of emotional meaning because you've shut down your limbic system. And there are only two ways for you to interpret this dilemma. Either you say the world isn't real - and that's called Derealisation. Or you say, I'm not real, I feel empty - and that's called Depersonalisation.
Epileptic seizures originating in this part of the brain can also produce these dreamy states of Derealisation and Depersonalisation. And, intriguingly, we know that during the actual seizure when the patient is experiencing Derealisation, you can obtain a Galvanic Skin Response and there's no response to anything. But once he comes out of the seizure, fine, he's normal. And all of this supports the hypothesis that I'm proposing."
©V.S. Ramachandran, M.D., Ph.D. |
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Summary, in my own words:
This theory could be disproved tomorrow but it helps me "get a handle" on what may have happened to me, why I have this illness. It also may be that I was born with some anomaly in my brain structure or neurochemistry that would have produced all of my symptoms regardless of the way I was raised; it is quite possible that my abuse had absolutely nothing to do with my current mental state. For now, I have settled on the Diathesis-Stress and Fight-Flight models and try to stop obsessing and asking, "Why me?" I must stop trying to control the situation. I need to accept my limitations and continue to improve and maintain the quality of my life.
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Further Required Reading:
Very important in understanding the spectrum of dissociative disorders from "healthy" to pathological. Every person experiences dissociation, but many are disabled by dissociation on the severe end of this spectrum.
Special Supplement: An entire volume of this prestigious publication dedicated to psychosomatic, anxiety, and dissociative disorders by multiple contributors.
"Many aspects of our personalities, it now seems clear, are inborn and resistant to change -- a fact, ironically, that makes the role of environment in our lives all the more important."
"Anxiety: It's up, way up, but don't let it get to you. Experts are learning to allay it by tracking its neurological and genetic paths."
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The touching words of Al Martinez as a 20 year old marine in the Korean War, now a columnist for The Los Angeles Times. This is an example of "healthy" dissociation in an untenable situation.
"I'm here seeking old battlefields. The driver tells me we've covered about 900 kilometers from Seoul to Taegu to the Hwachon Reservoir. We did it in two days. Back then, mountain by mountain, it took us nine bloody months.
I have a diary kept through most of my time in Korea. Much of it is in pencil, watermarked and hard to read. But I can make out sentences here and there. For instance on April 3, a Tuesday, I wrote, I'm beginning to feel detached from myself, as though it is someone else here, doing these things...
The feeling prevailed from the day our troop ship landed at Pusan until the day I left Seoul. I lived in a world reduced to essentials. Happiness was a beer ration. Grief was the sniper's mark on a guy like Cornhusker.
One minute alive, the next minute dead. Existence snapped in and out of focus that quickly." |
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© Sandy Gale, 2000-2008
The Pear Blossom Project 
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| April 17, 2008 |