Benoit Wolff interviews Elmar Kaiser.

BW : What are disorders of the self ?

EK : If we talk about disorders of the self, we mean states that are related to disintegration of the self, especially states related to the disintegration of one’s notion of body and mind.

BW : Can you name some ?

EK : Depersonalization and derealization. These are two special states that are connected to disintegration of the self. Depersonalization means that you do not know the borders of your body any longer. A person suffering from depersonalization might have the impression that she is losing control of her outer body borders, whereas in the case of derealization, the person perceives her environment as abnormal or changed and believes that it has become unreal or even frightening.

BW : So the person is suffering from hallucinations?

EK : Not necessarily. We have to differentiate these symptoms. Hallucinations occur in psychotic states or in a psychiatric disease like schizophrenia. Depersonalization and derealization are additional psychopathological symptoms that might occur in schizophrenia along with hallucinations. However, depersonalization and derealization are not hallucinations. Mostly, hallucinations are acoustic or visual. Bodily hallucinations areoccasionally reported by schizophrenic patients, as well. According to Karl Jaspers (1883-1969), one of the most important German psychiatrists and philosophers describing psychopathological symptoms, this phenomenon is called "Zoenästhesie". However, to my knowledge, this German word cannot be properly translated into Anglo-American literature. It is similar to what is called "cincture sensation" in English.

BW : To get back to depersonalization – is it the same as a multiple personality disorder ?

EK : That’s a tough question. Some experts say that depersonalization is a disorder, others assume it is an epiphenomenon of dissociative states occurring in personality disorders such as the well known borderline personality disorder. People suffering from borderline personality disorder experience repeated states of emotional instability, sometimes combined with symptoms of dissociation. Regarding the concept of the self, we should not imply that there are multiple selves in a person only because someone used the term “multiple personality disorders” and tried to implement it as a nosologic diagnostic group. In my very personal opinion, the phenomenon of a “multiple personality disorder” is a special dissociative state but not an independent disease.

BW : Is there a link between depersonalization or derealization and certain mental diseases ?

EK : Yes, as I stated, the most prominent one is schizophrenia. At the psychiatric hospital in Heidelberg we see a lot of patients showing symptoms such as depersonalization and derealization in relationship with the very complex disease of schizophrenia. But one cannot say that if someone suffers from depersonalization, he or she has to be diagnosed with schizophrenia, since this symptom is not the only clue to schizophrenia. Schizophrenia primarily affects formal thinking.  Several other symptoms not related to depersonalization or derealization may occur, too. Most people think of paranoia or acoustic and visual hallucinations, as illustrated in the very interesting movie, A Beautiful Mind. However, the scenic, optical hallucinations that the protagonist experiences in the movie are quite unlikely to occur in this form. Most schizophrenic patients describe optical hallucinations in vaguer forms – for example as disturbed colours, odd proportions of furniture in the room or as dark unspecific figures on the wall. Of course it is possible for optical hallucinations to become very concrete – however, this is more or less an exception to the rule.

BW : Speaking of derealization, could it be that it affects healthy people, too ? For example, if you meditate, you might experience a feeling of immensity and have the impression that you are nearly ‘borderless’. Is this a kind of derealization ?

EK : You’re right. This is indeed a form of depersonalization or derealization; it depends on what people experience. The oceanic feeling of being borderless and becoming “one with nature” is a prominent example of depersonalization in a healthy human being. This feeling of unification is not pathological. It is intended, and the person meditating wants to achieve it.

BW : Let me return to schizophrenia – how true is it that heavy use of marihuana can cause the disease ?

EK : Well, this is quite complicated again! On the one hand, it is definitely correct to assume that marihuana/cannabis and its main psychotropic substance THC has the potential to induce psychosis or schizophrenia (the definition depends on the duration of symptoms). On the other hand, we do not yet know who will experience a psychotic episode after having consumed THC. Some people consume it once or twice in their life and develop a psychosis, while others consume huge amounts of THC and they do not. The reason for this might be a genetic difference in the dopamine transporter system of the human brain. This system can be compared to a filter for sensory information (e.g. optical or acoustic information). It is a considerable task in scientific research to understand who is more prone to THC-induced psychosis and who is not. THC has dopamine agonistic effects. We assume that this system needs dopamine to filter information. If this system doesn’t function properly anymore, it might result in the affected person’s loss of control over received information in the human brain. In this situation it is absolutely likely for the person to develop a psychosis. Psychosis may include hallucinations, disintegration of the self, paranoia and malfunctioning of higher cognitive abilities.

BW : Is there any means to prevent schizophrenia, or dementia at a later age ?

EK : These are two different diseases. If we talk about schizophrenia we normally do so in connection with people in their twenties. There are different peaks for men and women. It is a disease that occurs early in life. Dementia is commonly diagnosed in sexagenarians; hence it is a disease of the elderly.

BW : How can these diseases be prevented?

EK : Both for schizophrenia and to a certain degree also for dementia of the Alzheimer type, there may be a genetic predisposition. Up to now, there is not much that can be done about this predisposition. However, avoiding stress can be helpful for people who are at high risk of developing psychosis and have a positive family history of schizophrenia. We do know that in schizophrenic patients, too much stress, or in other words too much information and tasks at the same time, can lead to psychotic states. People with a genetic predisposition should therefore be aware of their own limits. For example, they should try to have a plan for the week, try to sleep regularly and avoid drug or massive alcohol abuse. This is part of psychoeducation for patients with schizophrenia. Unfortunately, we do not have any curative medication for patients with Alzheimer’s disease. We can only treat symptoms of the disease but not its cause. For schizophrenia, it’s the same. There is quite a variety of antipsychotic medication available for treating symptoms. The common pharmacological principal is that these substances block the dopamine D2 transporter system. They reduce the symptoms of psychosis, such as hallucinations and paranoia, and improve formal thinking and integrity of the self.