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. Author manuscript; available in PMC: 2022 Aug 29.
Published in final edited form as: J Trauma Dissociation. 2020 Jan 30;21(3):337–348. doi: 10.1080/15299732.2020.1719259

Levels of Depersonalization and Derealization Reported by Recovered and Non-recovered Borderline Patients over 20 Years of Prospective Follow-Up

Ravi Shah 1,2, Christina M Temes 1,2, Frances R Frankenburg 1,3, Garrett M Fitzmaurice 2,4, Mary C Zanarini 1,2
PMCID: PMC9423009  NIHMSID: NIHMS1556421  PMID: 32000616

Borderline personality disorder (BPD) is a serious psychiatric illness characterized by emotion dysregulation, impulsivity, interpersonal problems, and poor psychosocial functioning, and it is often associated with dissociative symptoms. Borderline patients have consistently reported higher levels of dissociative symptoms compared to patients with other personality disorders or mental illnesses (Herman, Perry, & van der Kolk, 1989; Ross, 2007; Sar, Akyuz, Kugu, Ozturk, & Ertem-Vehid, 2006; Sar, Alioglu, & Akyuz, 2017; Simeon, Nelson, Elias, Greenberg, & Hollander, 2003; Zanarini, Ruser, Frankenburg, Hennen, & Gunderson, 2000). Dissociative symptoms result from a complex heterogeneous phenomenon where a person disconnects from their thoughts, feelings, memories, or sense of identity and are characterized by a wide range of psychological symptoms related to dissociative amnesia, dissociative identity disorder, and depersonalization-derealization disorder (Holmes et al., 2005; Spiegel & Cardena, 1991; Waller, Putnam, & Carlson, 1996).

Over the past two decades, several studies have utilized the dissociative experiences scale (DES) to study the severity of dissociative symptoms in borderline patients (Brodsky, Cloitre, & Dulit, 1995; Shearer, 1994; Zanarini, Frankenburg, Jager-Hyman, Reich, & Fitzmaurice, 2008; Zanarini, Ruser, Frankenburg, & Hennen, 2000). The DES is a self-report screening tool for dissociative disorders and captures three dissociative dimensions: absorption, depersonalization/derealization, and amnesia (Ross, Ellason, & Anderson, 1995; Ross, Joshi, & Currie, 1991; Sanders & Green, 1994). However, its sensitivity and specificity for depersonalization and derealization disorder has not been systematically addressed (Simeon et al., 1998). Depersonalization specifically refers to a sense of detachment from oneself and one’s identity (Nordqvist, 2019). It is often described as feeling unreal and completely numb such as out of body experiences, feeling like a robot, lack of physical or emotional responses to the external world. While an alteration in the perception of the external environment is referred as derealization, such as people and things aren’t real.

Community surveys using standardized diagnostic interviews have estimated the prevalence of depersonalization and derealization symptoms in the general population, and the rates were 0.5–2% in a UK sample and 2.4 % in a Canadian sample (Lee, Kwok, Hunter, Richards, & David, 2012). However, based on DSM-IV structured clinical interview for dissociative disorders in the U.S. clinical sample, the prevalence of depersonalization and derealization in borderline patients was found to be around 3.6% (Ross, 2007). Although depersonalization and derealization symptoms have been frequently observed in borderline patients, our understanding of the course of depersonalization and derealization symptoms over time and its role in BPD recovery is limited.

To our knowledge, this is the first longitudinal study to assess the course of depersonalization and derealization symptoms in recovered and non-recovered borderline patients over 20 years of prospective follow-up.

Method

The study utilized the data that was collected prospectively as a part of the McLean Study of Adult Development (MSAD), a multifaceted longitudinal study of the course of borderline personality disorder. The study was approved by the McLean Hospital Institutional Review Board, and the study methodology has been described in detailed in our previous publication (Zanarini, Frankenburg, Hennen, & Silk, 2003). Briefly, all participants were initially enrolled in the study from inpatient units at McLean Hospital in Belmont, Massachusetts. Each patient enrolled in the study was 18 to 35 years of age with a known or estimated IQ of 71 or higher, and had no history or current symptoms of bipolar I disorder, schizophrenia, schizoaffective disorder, or an organic condition that could cause serious psychiatric symptoms.

The details of the study procedures were explained to the participants prior to receiving a written informed consent to participate in the study. Four semi-structured interviews were administered by a masters-level interviewer who was blind to the patient’s clinical diagnoses: (1) Background Information Schedule (BIS) (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005; Zanarini, Frankenburg, Hennen, & Silk, 2004; Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010), (2) Structured Clinical Interview for DSM-III-R Axis I Disorders (SCID-I) (R. L. Spitzer, Williams, Gibbon, & First, 1992), (3) Revised Diagnostic Interview for Borderlines (DIB-R) (Zanarini, Gunderson, Frankenburg, & Chauncey, 1989), and (4) Diagnostic Interview for DSM-III-R Personality Disorders (DIPD-R) (Zanarini, Frankenburg, Chauncey, & Gunderson, 1987). Good to excellent inter-rater and test-retest reliability were found for the BIS (Zanarini et al., 2005; Zanarini et al., 2004) and these three diagnostic measures (Zanarini & Frankenburg, 2001; Zanarini, Frankenburg, & Vujanovic, 2002).

Ten follow-up interviews separated by 2 years were conducted over 20 years using interview methods similar to those used at baseline and diagnostic status was reassessed by staff members blind to baseline diagnoses. The diagnostic battery was re-administered after receiving written informed consent from the participants. At each time period, social and vocational functioning was also assessed using the follow-up analog of the Background Information Schedule—the Revised Borderline Follow-up Interview (BIF-R) (Zanarini, Sickel, Yong, & Glazer, 1994).

In this study, three items from the Dysphoric Affect Scale (DAS) were used to evaluate the level of depersonalization and derealization experienced by borderline patients. These three items were: “feeling unreal,” “feeling completely numb,” and “feeling like people and things aren’t real.” The DAS is a self-report measure consisting of 50 items to comprehensively assess dysphoric affective and cognitive states of borderline patients. The participants reported the percentage of time (ranging from 0–100%) that they had experienced each item during the past month. The psychometric properties of the DAS are found to be excellent (Reed, Fitzmaurice, & Zanarini, 2012), with very high internal consistency (Cronbach’s α = 0.97) and test-retest reliability of 0.97 when examined in a sample of 15 nonpsychotic outpatients.

We compared recovered to non-recovered borderline patients. The participants were considered recovered if they achieved a concurrent symptomatic remission from BPD and had at least one emotionally sustaining relationship with a close friend or life partner/spouse, and were able to work or go to school consistently, competently, and on a full-time basis during the two-year interval.

Statistical Analyses

Descriptive analyses (means, standard deviations, percentages, frequencies) for all the variables were calculated to characterize study participants based on recovery from borderline personality disorder. The longitudinal linear analyses were conducted using the generalized estimating equations (GEE) approach to assess the level of dissociation over 20 years of follow-up. The association among the repeated measures of time, recovery, and dissociation over time can be analyzed appropriately by the GEE approach. These analyses included the effects of recovery group, time, and their possible interaction to see linear change in the mean level over time.

The DAS was introduced in the study about two-thirds of the way through baseline data collection. As a result, only 140 out of 290 participants completed DAS at baseline. Additionally, 18 participants did not complete DAS at the 18-year and 20-year follow up assessments. For the purpose of this study, missing data in these three inner states were handled by a multiple imputation procedure, which predicted the missing baseline and 18 and 20-year follow-up data using both diagnostic and follow-up data (one inner state at a time). In particular, the imputation model provided a random set of 10 plausible values for each missing data, which were then appropriately combined to provide a single estimate of the parameters of interest.

Results

At study entry, 290 inpatients met DIB-R and DSM-III-R criteria for BPD. The demographic information of the study participants at baseline have been reported elsewhere (Zanarini et al., 2003). Briefly, the majority of the study participants were white (87.2%, n=253), female (80.3%, n=233) with an average age of 26.9 years (SD=5.8). The mean socioeconomic status was 3.4 (SD=1.5) (where 1=highest and 5=lowest) and their mean GAF score was 38.9 (SD=7.5). The number of participants decreased slightly over the 20 years of follow-up; 13 died by suicide and 19 died of other causes. However, 85% of surviving patients (220/258) with borderline personality disorder completed our assessment battery at all ten follow-up waves.

The mean scores of the three inner states reflecting level of depersonalization and derealization reported by recovered (n=152) and non-recovered (n=138) borderline patients can be seen in Table 1. Table 1 also indicates the relative differences (RD) between recovered and non-recovered borderline patients and relative change in their mean scores over time for both groups. Furthermore, our statistical analyses indicated significant recovery status group by time interactions in these three inner states. Therefore, scores of recovered and non-recovered groups decreased significantly but at a different rate over 20 years of prospective follow-up.

Table 1:

Percentage of Time Dissociation Symptoms Reported by Recovered and Non-recovered Borderline Patients (Mean and SD)

BL (N=290) 2 YR FU (N=275) 4 YR FU (N=269) 6 YR FU (N=264) 8 YR FU (N=255) 10 YR FU (N=249) 12 YR FU (N=244) 14 YR FU (N=238) 16 YR FU (N=231) 18 YR FU (N=224) 20 YR FU (N=220) Rel. Diff. Recovery Δ Recovered Δ Non-recovered 95% CI Recovery Δ Recovered Δ Non-recovered
Feeling unreal
Recovered 22.3 (28.1) 10.9 (21.7) 9.4 (22.6) 5.1 (11.6) 5.0 (12.6) 3.5 (9.7) 2.9 (8.9) 4.5 (13.8) 3.8 (11.5) 3.1 (10.2) 3.3 (12.5) 0.37
0.21		 0.21–0.67
0.13 – 0.32
Non-Recovered 34.4 (36.4) 27.9 (33.4) 23.4 (30.4) 19.3 (27.7) 20.1 (27.5) 16.6 (25.8) 14.9 (24.8) 13.9 (23.4) 14.5 (24.2) 14.0 (22.7) 12.8 (24.3) 0.15 0.08 −0.26
Feeling completely numb
Recovered 24.8 (27.8) 13.0 (21.7) 9.5 (19.1) 7.4 (14.0) 5.8 (11.1) 3.9 (10.0) 3.5 (10.3) 4.0 (10.6) 4.0 (10.7) 3.4 (11.1) 6.1 (16.6) 0.38
0.14		 0.22 – 0.64
0.09 – 0.22
Non-Recovered 36.3 (32.4) 28.4 (31.5) 25.1 (30.0) 19.7 (27.3) 19.6 (27.4) 18.3 (26.1) 17.8 (27.8) 15.6 (21.9) 14.7 (22.5) 12.7 (22.0) 17.3 (26.4) 0.15 0.08 – 0.24
Feeling like people and things aren’t real
Recovered 13.7 (22.3) 6.5 (17.5) 6.3 (18.2) 3.1 (9.1) 3.4 (10.4) 2.2 (8.8) 1.8 (7.8) 2.0 (8.1) 1.8 (6.1) 1.4 (7.1) 2.8 (12.5) 0.37
0.29		 0.21 – 0.65
0.19 – 0.42
Non-Recovered 23.0 (28.9) 18.6 (28.2) 17.1 (26.1) 14.1 (23.6) 15.5 (24.2) 14.0 (23.6) 11.7 (23.1) 9.7 (19.3) 10.7 (18.7) 8.6 (17.7) 9.3 (20.3) 0.21 0.13 – 0.33
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Statistical analyses of the inner state “feeling unreal” indicate that patients who recovered from BPD had baseline scores that were 63% lower than those reported by non-recovered patients. When both groups were compared in terms of relative change over 20 years of follow-up, the patients who recovered from BPD reported a significant (P<0.001) decrease of 79% ([0.21–1] × 100%) in “feeling unreal” whereas those who did not recover reported a significant (P<0.001) decrease of 85% ([0.15–1] × 100%). Furthermore, there was a significant (P<0.001) between-group difference in relative change based on a 2-degree of freedom test of recovery status and time interaction.

Similarly, our statistical analyses of the inner state “feeling completely numb” indicated a similar pattern. The patients who recovered from BPD had baseline scores that were 62% lower than those reported by non-recovered patients. When both groups were compared in terms of relative change over 20 years of follow-up, the patients who recovered from BPD reported a significant (P<0.001) decrease of 86% ([0.14–1] × 100%) in “feeling completely numb” whereas those who did not recover reported a significant (P<0.001) decrease of 85% ([0.15–1] × 100%). Furthermore, there was a significant (P<0.001) between-group difference in relative change based on a 2-degree of freedom test of recovery status and time interaction.

Furthermore, our statistical analyses for the inner state “feeling like people and things aren’t real” indicate that patients who recovered from BPD had baseline scores that were 63% lower than those reported by non-recovered patients. When both groups were compared in terms of relative change over 20 years of follow-up, the patients who recovered from BPD reported a significant (P<0.001) decrease of 71% ([0.29–1] × 100%) in “feeling like people and things aren’t real” whereas those who did not recover reported a significant (P<0.001) decrease of 79% ([0.21–1] × 100%). Furthermore, there was a significant (P<0.001) between-group difference in relative change based on a 2-degree of freedom test of recovery status and time interaction.

Additional statistical analyses were conducted to explore the correlations of the three inner states with each other and with the total DAS score (excluding these three items). The Pearson correlation of the inner state “feeling unreal” was significantly and positively related to “feeling completely numb” (r=0.64; P<0.001), “feeling like people and things aren’t real” (r=0.74; P<0.001), and the total DAS score (r=0.55; P<0.001). Similarly, the Pearson correlation of the inner state “feeling completely numb” was significantly and positively related to the total DAS score (r=0.59; P<0.001). Furthermore, the inner state “feeling like people and things aren’t real” was significantly and positively associated with the inner state “feeling completely numb” (r=0.56; P<0.001) and the total DAS score (r=0.43; P<0.001)”.

Discussion

This study was designed to evaluate the course of three inner states reflecting depersonalization and derealization symptoms in recovered and non-recovered borderline patients over 20 years of prospective follow-up. It is also important to note that the current study utilized the complex outcome of recovery reported by Zanarini and her colleagues (2012).

Two important and clinically relevant findings have emerged from the results of this study. The first important finding is that the patients who recovered from BPD reported significantly lower scores at baseline compared to those patients who did not recover. Specifically, the recovered group had significantly lower scores at baseline in all three inner states compared to non-recovered group. To our knowledge, no other studies have compared depersonalization (feeling unreal and feeling completely numb) and derealization (feeling like people and things aren’t real) symptoms in borderline patients based on their recovery status. However, the study conducted by (Zanarini et al., 2008) compared the levels of dissociative symptoms experienced by borderline and other personality- disordered patients over 10 years of prospective follow-up. In particular, their findings suggest that the levels of dissociation (including depersonalization) experienced by borderline patients were significantly higher than those with other personality disorders. It is also important to note that higher baseline dissociative symptoms have also been observed in patients with other disorders such as eating disorders (La Mela, Maglietta, Castellini, Amoroso, & Lucarelli, 2010) and PTSD (Murphy & Busuttil, 2015). Furthermore, several studies have demonstrated the impact of baseline dissociation on treatment outcome of various mental disorders such as affective, anxiety, and somatoform disorders (C. Spitzer, Barnow, Freyberger, & Grabe, 2007), PTSD (Resick, Suvak, Johnides, Mitchell, & Iverson, 2012), and anxiety and depression (Prasko et al., 2016). Overall, these findings are very important for clinicians treating borderline patients and highlight the adverse consequences of depersonalization and derealization in BPD recovery. It also indicates that depersonalization and derealization symptoms in borderline patients should not be ignored and an appropriate treatment option such as dialectical behavior therapy (DBT) (Linehan, 1987), mentalization-based therapy (MBT) (Bateman & Fonagy, 2010), transference-focused therapy (TFT) (O. F. Kernberg, Yeomans, Clarkin, & Levy, 2008), general psychiatric management (GPM) (McMain et al., 2009), or psychotropic medications should be considered.

The second important finding is that scores of recovered and non-recovered groups decreased significantly in all three inner states studied over 20 years of prospective follow-up. Specifically, the patients who recovered from BPD had a significant relative decrease of 71–86% in these three inner states while those patients who did not recover had a significant relative decrease of 79–85%. Since the non-recovered group had much higher (62–63%) baseline scores, their adjusted scores after relative decrease were still higher than the recovered group over 20 years of perspective follow-up. This finding is consistent with the previously reported downward trend of dissociative symptoms observed in borderline patients (Zanarini et al., 2008). In particular, findings from (Zanarini et al., 2008) suggest that all types of dissociative experiences declined significantly in severity over 10 years of prospective follow-up for borderline patients compared to other personality disorders. Taken together, these findings provide hope to borderline patients with serious depersonalization and derealization symptoms and the clinicians treating them.

Although previous studies have consistently demonstrated higher prevalence of dissociative symptoms in borderline patients (Ross, 2007; Sar et al., 2006; Zanarini, Ruser, Frankenburg, Hennen, et al., 2000), it is not clear how dissociative symptoms interfere with BPD recovery. One possible explanation would be the use of splitting as a defense mechanism, which is fairly common in borderline patients (Zanarini, Frankenburg, & Fitzmaurice, 2013). Splitting contributes to unstable relationships and intense emotional experiences, and extreme degrees of internal splitting can result in fragmentation of self through the mechanism of dissociation (O. Kernberg, 1967). The current study demonstrated a significant association between the percentage of time borderline patients experienced three inner states related to depersonalization and derealization and BPD recovery. However, it is difficult to know the directionality of association, for example, if the decline in dissociative symptoms was due to BPD recovery, or if recovery status was influencing the reduction in dissociative symptoms. It is also not clear if the decline in dissociative symptoms can be attributed to treatment, the passage of time, the support offered by family and friends, or some combination of these factors. Future research is needed to understand the nature and direction of associations between dissociative symptoms and BPD recovery.

Limitations

The findings of this study must be interpreted in light of some limitations. First, the results of this study were based on seriously impaired borderline patients recruited from psychiatric inpatient units. It is possible that borderline patients visiting outpatient clinics or those residing in the community may have less severe impairment and dissociation, and these findings may not be generalized to these groups. Second, the majority of patients were receiving outpatient treatment such as psychotherapy, psychotropic medications or both (Zanarini, Frankenburg, Bradford Reich, Harned, & Fitzmaurice, 2015), and it is difficult to know how these treatments would affect recovery status. Therefore, it may not be generalized to untreated borderline patients. Third, the study is based on three inner states reflecting level of depersonalization and derealization. Although the psychometric properties of the DAS are found to be excellent with very high internal consistency and test-retest reliability, individual item on DAS has not been validated. Therefore, the findings of the study may not be compared with dissociative measures used in other population.

Conclusions

Taken together, the results of this study suggest that depersonalization and derealization symptoms decreased significantly over 20 years of prospective follow-up. Furthermore, depersonalization and derealization symptoms seem to have strong association with BPD recovery status.

Acknowledgments

This study was supported by NIMH grants MH47588 and MH62169.

Footnotes

The authors report no relevant conflicts of interest.

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