The Man Who Wasn't There: Investigations into the Strange New Science of the Self (19 page)

Nicholas was about twelve when he became chronically depersonalized—an episode that lasted four years. “The most terrifying thing about having it at that age was that I didn’t have any support,” he told me. No parents, no teachers, no friends that he could speak to. His sister was too young to understand.

It didn’t help that they didn’t have a stable home. Their mother and stepfather were eventually arrested on charges of drug abuse and child neglect. Nicholas and his sister were again living in group homes, or with foster parents. Around the time he turned thirteen or fourteen
(the time line is hazy in his mind, something he attributes to depersonalization), Nicholas was reintroduced to his biological father. His mother had filled him with hatred for his father. Nicholas wanted to see what he was really like. By then, his father had spent four years in jail, was tattooed—not the colorful ones like Nicholas now has, but the dark, bluish-black ones common among prisoners—and had bulked up in prison. “He was some two-hundred-odd pounds of muscle,” said Nicholas. “He looked like a body builder.”

Moving in with his father turned out to be disastrous. His father was living with his own stepfather, and both were doing drugs. They paid no heed to Nicholas. In fact, Nicholas’s stepgrandfather (for want of a better word) would buy him alcohol. The young Nicholas, barely fourteen, slipped headlong into a world of liquor, weed, and other drugs. He was soon intravenously injecting himself with morphine. “That was my rock bottom, as far as addiction goes,” he said. Meanwhile, his foster family—whom he had run away from to live with his father—informed the authorities that Nicholas was in serious danger.

Nicholas’s now fiancée, Jasmine, recalled the day he was whisked away to rehab. Jasmine was with her friends in downtown Liverpool, Nova Scotia, when a friend ran up yelling, “Nick was arrested!” Jasmine had met Nicholas just the week before. Suddenly he was off to jail. But it wasn’t jail he was going to: the Department of Community Services was taking him to rehab. At first he was sent to a secure care facility in Truro, where he detoxed for a month. Then he spent nine months in a rehab center in Sussex, New Brunswick. Sometime during the rehab, he went into remission—his depersonalization disappeared.

When he finished rehab, a young couple in their thirties—Tammy and Dave—took him in. I spoke to Tammy about how she and her husband were charmed by the well-spoken and likeable teenager.
“When we met Nick I’d say we both fell in love with him,” she told me. “By the time we encountered any difficult times with him, we both loved him like our own.” Nicholas had serious difficulties, however. He was ridden with anxiety; he could only be alone while sleeping. He was terrified of large buildings. “He didn’t go to Walmart, for example,” said Tammy. “There was something about the way it looked and felt that meant he couldn’t get out of the car at Walmart.” Tammy also noticed something amiss about the way Nicholas felt about people. “Especially with new relationships, he spoke of not feeling what he thought other people must feel. And yet, things still seemed to hurt him.” She also doesn’t remember him exulting in anything. “He certainly has been happy in his life, but not elated.”

The couple took all that in stride, which meant the world to Nicholas. “They treated me as if I was their own child. It was huge for me. I lived there for three to four years, and in those three to four years I learned responsibility, accountability . . . all kinds of things I hadn’t been raised to learn,” said Nicholas. He learned to drive, got his license, went back to school, and got his diploma. That’s also when he started getting his tattoos—something that his foster parents weren’t terribly keen on, but nonetheless they got a kick out of seeing Nicholas tattooing their initials on his wrist.

The remission from depersonalization was itself anticlimactic. Life returned to normal. No firecrackers went off. “Depersonalization becomes a very, very faint memory in the background,” said Nicholas. He quit smoking (he had sworn off drugs, except for one relapse after rehab), exercised a lot, and life was relatively good. “When I look back at my life, those three years are the zenith of my life,” he told me.

During his remission, Nicholas sought a lawyer’s help to see his file at the Department of Community Services. In the file he saw the
list of disorders he had been diagnosed with: “Depersonalization disorder, OCD, generalized anxiety disorder, and another one called oppositional-defiant disorder.”

His remission wouldn’t last. One day, while at work in a call center, Nicholas drank a large can of an energy drink, which was loaded with caffeine and taurine. It triggered a massive panic attack. The attacks came frequently thereafter. “They started to get worse and worse and more frequent, and very, very intense,” recalled Nicholas. “[I’d be] thinking that I’m dying at the time of the panic attack.” Worse yet, the depersonalization returned, something he had forgotten about.

“Even the simplest things feel strange when you have depersonalization,” he said. “You become so hyperaware of things. Opening and closing your hands, or moving your arms when you walk, or even walking itself, all those things become very strange, because you do not feel it’s you doing them. It feels like you are sending commands to somebody else to do it for you.” (This is reminiscent of what Sophie and Laurie said about their experiences with schizophrenia. Many people with schizophrenia show signs of depersonalization in their prodromal phase, before progressing to full-blown schizophrenia.)

Meanwhile, Nicholas started dating Jasmine. The relationship was hard at first. Jasmine would point out that Nicholas didn’t seem to care, or be emotionally invested; he seemed distant, preoccupied. Slowly, Nicholas explained that it wasn’t him; it was his depersonalization that was the problem. He felt emotionally numb toward everything.

The numbness remained even after they got engaged. “It’s like she is not actually my fiancée. I know that she is and I know that I love her, but it doesn’t feel like she is somebody I know. It’s almost like not recognizing somebody but you do. It’s odd,” Nicholas told me. “I have
talked to other people about this too who had the same thing. They know they love the person they are with, and they are aware of that, but it feels that the person is a stranger. You don’t have a full connection.”

And then his daughter was born. Nicholas was in the delivery room helping. He watched his daughter enter the world. “I had waited so long for her to be born, and it was such a big event. I cried when she was born and I felt it. For her birth, I was tapped in,” said Nicholas. “I haven’t experienced [such feelings] since, but I’m so glad I did experience that. There have been so many situations, with her, and with deaths of friends, where I didn’t feel it fully, but for some reason, my daughter’s birth was an exception to that.”

Emotional numbness in depersonalization is a paradox. It’s clear that people who suffer are unable to feel intensely—as is evident from Nicholas’s descriptions—yet they are distressed and panicked, which are also feeling states.

Nick Medford, a neuropsychiatrist at Brighton and Sussex Medical School in England, recalled a woman patient of his who exemplified this paradox. The family living next door to the patient had just suffered a horrible tragedy: their young child had been killed in a terrible accident. “She knew that the appropriate things to say were ‘that’s terrible, I’m so sorry, that’s awful,’ but she said she didn’t feel anything about it,” Medford told me. “But then she felt disturbed by the fact that she didn’t feel anything.”

Another patient told him, “I don’t have any emotions—it makes me so unhappy.”

“It’s sort of contradictory,” said Medford. “If you unpack that, I
think what people are describing is that they have a lot of internal emotional distress or turmoil, but they don’t seem to have emotional reactivity to external things.”

It’s very clear that people with depersonalization are experiencing muted emotions, an altered sense of one’s body, and an altered sense of reality. Something is amiss in the body-brain system that generates feelings of body states. Sufferers are also prone to self-rumination—that is, giving excessive thought to their altered state, and potentially greatly reducing the attention they pay to the external world (recall Steven Laureys’s finding about external and internal awareness networks, and how they are inversely correlated—one works at the expense of the other). Self-rumination may also “
contribute to the sense that the world has become somehow distant and unreal.”

Jeff Abugel, an author of two books on depersonalization, and the person who introduced me to Nicholas, is someone who knows about such obsession. He has experienced transient episodes of depersonalization since his late teens. During these episodes, “virtually everything that constituted my life mentally had kind of disappeared. The only thing that was left was this nonstop sensation of trying to figure out what was wrong with me,” he said. “My whole existence became just pondering: what’s wrong with me, why do I feel this way, what’s going on?”

So, while the feelings of distress and unhappiness seem to be the result of an obsessive focus on the sense of strangeness, the strangeness has its basis in the way emotional feeling states are generated—and how they underpin the sense of self.

Medford and his colleagues have studied the emotional response of patients while they lay inside a scanner. If a person with an intact emotional system is shown emotionally positive, neutral, or negative
images, the scanner shows brain activations appropriate to each type of stimulus. One of the brain regions that is activated when viewing emotionally salient images is the insula. Activity in the insula is correlated with “
every conceivable kind of feeling,” writes Damasio in
Self Comes to Mind
, “from those that are associated with emotions to those that correspond to any shade of pleasure or pain, induced by a wide range of stimuli: hearing music one likes or hates; viewing pictures one loves, including erotic material, or pictures that cause disgust; drinking wine; having sex; being high on drugs; being low on drugs and experiencing withdrawal; and so forth” (recall the case of the sixty-five-year-old woman with dementia who suffered from Cotard’s syndrome: she had bilateral insular atrophy, potentially messing with her bodily feeling states). In depersonalization, Medford’s team found that there is distinctly less activity in the left anterior insula while viewing aversive images when compared with healthy controls. “The emotional circuitry, emotional responses, seem to be switched off somehow,” Medford told me.

The switch lies elsewhere in the brain. Another brain region that has been regularly implicated in depersonalization is the ventrolateral prefrontal cortex (VLPFC)—an area of the brain that’s involved in top-down control of emotions. Medford’s study (one of the largest ever done, with fourteen depersonalization patients) found that the VLPFC was overactive in these patients when compared with controls. An overactive VLPFC might be suppressing emotional responses in depersonalization.

The team took the study one step further. While there are no known medications for depersonalization, some people have reported improvements when they have taken lamotrigine, an anticonvulsant prescribed for epilepsy. Ten of the fourteen patients in Medford’s study
took lamotrigine for four to eight months, after which they agreed to be scanned again. Some patients reported that their condition had improved, while in others there was no change. Those whose symptoms had abated
showed increased activity in the left anterior insula and decreased activity in the VLPFC when compared to the scans from before they began taking lamotrigine and when compared to the scans of those who were not feeling better despite the pharmacotherapy. “Whereas the people that hadn’t improved at all, they were still very flat in terms of neural responses,” said Medford, of the activity in the insula.

The left anterior insula is involved in integrating sensations from both inside the body (interoceptive) and outside (exteroceptive), and is thought to be crucial for creating a subjective sense of our own body and indeed for the sense of self. Neuroanatomist Bud Craig, who has done seminal work to understand the neuroanatomy of the insula, argues that it provides the neural substrate for the “sentient self.” Antonio Damasio begs to differ (arguing that the brain stem too has an important role to play in representing body states).

While the VLPFC in people with depersonalization can be said to be “switching off” the left anterior insula, it’s not under conscious control. “It’s not a willed thing,” said Medford. “It’s just happening. Things are being switched off.”

If so, this switching off should become apparent in how autonomic nervous system responses—which are not under conscious control—operate in people with depersonalization. And in fact, that’s exactly what researchers have seen: if you measure skin conductance of the hand (an autonomic response) in reaction to unpleasant stimuli, people with depersonalization show very little activity. “When you have a patient with depersonalization wired up to measure skin conductance,
you are constantly checking to see if the thing’s actually [connected],” said Medford. “Because you just get this flat line, which is not what you normally see.”