DEPRESSION AND ANXIETY 15:172–175 (2002)

Research Article
INSTRUMENT TO ASSESS DEPERSONALIZATION-
DEREALIZATION IN PANIC DISORDER
Brian J. Cox, Ph.D.,1* and Richard P. Swinson, M.D.2

There is a long history of scholarly interest on depersonalization-derealization

(DD) and its role in clinical anxiety, but there is a paucity of appropriate
assessment instruments available. Our objective was to develop and evaluate a
self-report measure of DD for use with clinically anxious patients. Panic
disorder patients (n=169) were surveyed about DD experiences and provided
data on a new item pool for psychometric development. DD episodes were
common and a 28-item Depersonalization-Derealization Inventory was found
to possess good reliability and validity. DD appears to be prevalent and clinically
relevant in panic disorder. Continued study of DD is warranted and may be
facilitated by the availability of a suitable instrument with promising
psychometric properties. A 12-item version of the instrument may be
appropriate as a brief screen. Depression and Anxiety 15:172–175,
2002. & 2002 Wiley-Liss, Inc.

Key words: depersonalization; feelings of unreality; panic disorder; panic

attacks; assessment

found to dif ferentiate depersonalization disorder pa-

INTRODUCTION
I nterest in clinical anxiety and depersonalization (self)
and derealization (surroundings) dates back to Roth’s
[1959] seminal writings on ‘‘phobic anxiety-deperso-
nalization syndrome’’ as a distinct form of neurotic
illness. Symptoms of depersonalization-derealization
(DD) seem to be particularly salient in the case of panic
disorder and may indicate a more severe clinical course
[Cassano et al., 1989]. There have been several studies
on pharmacologic treatments and on possible biologi-
cal underpinnings of DD [Edlund et al., 1987;
Hollander et al., 1990; Noyes et al., 1987; Stein and
Uhde, 1989], history of childhood trauma in panic
disorder patients who report depersonalization/
derealization during attacks [Marshall et al., 2000;
McWilliams et al., 2001], and even on techniques to
induce DD which might then be developed into
behavior therapy (exposure) approaches [Miller et al.,
1994]. Given the longstanding interest in DD, it is
surprising that no published instrument exists to
reliably and validly assess this phenomenology in
clinical anxiety states. There have instead been greater
efforts to measure depersonalization in a dissociative
disorders context [Steinberg, 1991] rather than as an
anxiety-related phenomenon. For example, ‘‘amnesia’’
is a common factor assessed [Simeon et al., 1998], and
the fact that a new measure of depersonalization was
tients from clinically anxious patients was viewed as
evidence of its validity [Sierra and Berrios, 2000]. We
sought to help fill this measurement void in the anxiety
literature, as well as to provide additional information
on the prevalence and nature of DD episodes in panic
disorder patients. In developing the item pool, we were
largely guided by the rich clinical descriptions of DD
that have appeared in the literature, many of which
span several decades [Brauer et al., 1970; Davison,
1964; Harper and Roth, 1962; Roth, 1959]. We were
especially directed towards symptoms that were men-
tioned more than once.
1
Department of Psychiatry, University of Manitoba, Manitoba,
Canada
2
Department of Psychiatry and Behavioral Neurosciences,
McMaster University, Ontario, Canada
*Correspondence to: Dr. B. Cox, PZ-430 PsycHealth Centre, 771
Bannatyne Ave., Winnipeg, MB, Canada, R3E 3N4. E-mail:
coxbj@cc.umanitoba.ca
Received for publication 5 May 2000; Revised 11 December
2000; Accepted 30 December 2000
DOI: 10.1002/da.10051
Published online in Wiley InterScience
(www.interscience.wiley.com).

& 2002 WILEY-LISS, INC.

 Research Article: Depersonalization-Derealization Inventory
METHODS
SUBJECTS
The sample in this study was comprised of 169 panic
disorder patients (60 men, 109 women) with a mean
age of 34.28 years (S.D.=9.26). One hundred forty-nine
of these patients had accompanying agoraphobia.
Patients reported a mean of 4.30 panic attacks
(S.D.=3.97) in the 4-week period prior to testing.
MATERIALS AND PROCEDURES
All patients were consecutive referrals to an anxiety
disorders clinic in a university teaching hospital. Most
of the patients were initially screened by telephone to
ensure they had a primary diagnosis of anxiety disorder.
Patients were diagnosed using DSM-III-R [American
Psychiatric Association, 1987] or DSM-IV [American
Psychiatric Association, 1994] criteria following a 1- to
2-hr clinical interview conducted by either a psychia-
trist or clinical psychologist.
As part of the assessment phase, patients completed
the Fear Questionnaire-Agoraphobia subscale (FQ-Ag)
[Marks and Mathews, 1979], Beck Depression Inven-
tory (BDI) [Beck et al., 1961], Beck Anxiety Inventory
(BAI) [Beck et al., 1988], Symptom Checklist 90-
Somatization subscale (SCL-Som) [Derogatis et al.,
1973], and a revised version of the Panic Attack
Questionnaire (PAQ) [Cox et al., 1992; Norton et al.,
1986].
DEVELOPMENT OF DEPERSONALIZATION-
DEREALIZATION INVENTORY
Items were generated based on published clinical
descriptions of DD phenomena and our own clinical
observations. A 40-item scale was initially developed
and severity for each item was coded on a 5-point scale
where 0=does not occur, 1=mild, 2=moderate, 3=severe,
and 4=very severe.
Patients were asked to complete the scale if they
answered in the affirmative to the following statement
which appeared at the beginning of the scale: ‘‘Some-
times people with anxiety problems report episodes in
which they feel strange and detached from their
surroundings. These feelings of unreality are often
labelled by people as feeling ‘spacy’ or ‘spaced out’.
This type of feeling may occur as part of a panic attack
or it may happen at other times. Do you ever have these
type of experiences?’’ Although a time frame was not
specified, the word ‘‘ever’’ in this statement implies a
lifetime prevalence.
Item selection involved removing items from the
initial pool administered to those patients who
reported DD episodes based on the following criteria:
item-total correlation < 0.40; non-significant correla-
tion with the panic symptom ‘‘feeling of unreality;’’ a
mean severity rating of < 1.0; or cases where two items
had very similar wording. This resulted in the deletion
of 12 items, leaving a final 28-item version which we
173
have labeled the Depersonalization-Derealization In-
ventory (DDI). To ensure that individuals with both
mild and severe DD experienced similar symptoms, we
compared the original, 40-item scale profiles of
patients who scored at least one standard deviation
below the scale mean to the scale profiles of patients
who scored at least one standard deviation above the
scale mean. The pattern of severity ratings was very
similar. The profiles of the 40-item severity ratings
were also compared between men and women and
again the pattern was very similar.
RESULTS
One-hundred-twenty of the 169 panic disorder
patients responded affirmatively to the description of
episodes of DD (71.0%) and 116 patients completed
the DDI (41 men, 75 women). The total score on this
28-item scale was 50.16 (S.D.=24.36) and the mean
item severity was 1.78 (S.D.=0.86). The scale was found
to have excellent internal consistency (alpha=0.95).
Table 1 presents descriptive statistics on the individual
items that make up the DDI and the rank order of
mean severity for each item. These rankings could be
used to cull items in order to create a brief version of
the DDI (for example, 12 items with highest rankings).
Correlations between the DDI and other symptom
measures were as follows: Beck Anxiety Inventory
(r=0.52, P< 0.001), Beck Depression Inventory (r=0.44,
P< 0.001), Fear Questionnaire-Agoraphobia subscale
(r=0.25, P< 0.01), Symptom Checklist-Somatization
subscale (r=0.50, P< 0.001), and Panic Attack Ques-
tionnaire-Symptom Severity (r=0.56, P< 0.001). The
panic symptoms most highly correlated with the DDI
were: feeling of unreality (r=0.59, P< 0.001) and fear of
losing control (r=0.41, P< 0.001).
COMPARISONS BETWEEN PANIC
DISORDER PATIENTS WITH DD EPISODES
VERSUS THOSE WITHOUT DD EPISODES
There were no significant differences between the
two groups on gender distribution, and scores on the
FQ-Ag and BDI. Patients with DD were younger
(M=32.87, S.D.=8.31) compared to patients without
these episodes (M=37.73, S.D.=10.57), t(167)=2.88,
P< 0.01. Patients with DD had significantly higher
scores on the BAI (M=29.43, S.D.=13.88) compared to
the other patients (M=21.71, S.D.=12.78), t(152)=3.14,
P< 0.005, and also scored significantly higher on the
SCL-Som (M=17.23, S.D.=10.40) compared to patients
without these episodes (M=12.88, S.D.=7.78), t(165)=
2.95, P< 0.005. DD patients reported significantly more
panic attacks in the past 4 weeks (M=4.81, S.D.=4.12)
compared to patients without these episodes (M=3.04,
S.D.=3.28), t(163)=2.65, P< 0.01. The two groups of
patients were also compared on the severity ratings of
the 16 panic attack symptoms listed in the Panic Attack
Questionnaire. After adjusting the significance level for
174 Cox and Swinson

TABLE 1. Depersonalization-derealization inventory descriptive statistics for panic disorder patients who reported
depersonalization-derealization episodes (n=116)*

Item Mean S.D. Rank order of severity

1. Surroundings seem strange or unreal 1.84 1.28 11
2. Time seems to pass very slowly 1.60 1.34 18
3. Body feels strange or different in some way 2.23 1.21 6
4. Feel like you’ve been here before (deja vu) 1.44 1.32 22
5. Feel as though in a dream 1.61 1.36 16.5
6. Body feels numb 1.41 1.26 23.5
7. Feeling of detachment or separation from surroundings 2.32 1.26 5
8. Numbing of emotions 1.41 1.31 23.5
9. People and objects seem far away 1.61 1.40 16.5
10. Feeling detached or separated from your body 1.67 1.35 12
11. Thoughts seem blurred 2.02 1.29 8.5
12. Events seem to happen in slow motion 1.35 1.37 26.5
13. Your emotions seem disconnected from yourself 1.35 1.30 26.5
14. Feeling of not being in control of self 2.68 1.13 2
15. People appear strange or unreal 1.48 1.45 20
16. Dizziness 2.02 1.26 8.5
17. Surroundings appear covered with a haze 1.59 1.40 19
18. Vision is dulled 1.46 1.29 21
19. Feel as if walking on shifting ground 1.64 1.44 13
20. Difficulty understanding what others say to you 1.40 1.30 25
21. Difficulty focusing attention 2.69 1.12 1
22. Feel as though in a trance 1.49 1.30 19
23. The distinction between close and distant is blurred 1.05 1.15 28
24. Difficulty concentrating 2.60 1.12 3
25. Feel as though your personality is different 1.63 1.52 14
26. Feel confused or bewildered 2.06 1.35 7
27. Feel isolated from the world 2.01 1.50 10
28. Feel ‘‘spacy’’ or ‘‘spaced out’’ 2.48 1.24 4

*For the purpose of replication, items are presented in the order they appeared in the original scale administered to the patients. Items were scored on a 5-point
scale where 0=does not occur, and 4=very severe.

multiple comparisons (0.05/16=0.003), it was found
that DD patients had significantly higher severity
ratings for dizziness, t(164)=3.64, P< 0.001; feelings of
unreality, t(162)= 4.98, P< 0.001; faintness, t(165)=3.04,
P< 0.003; and fear of losing control; t(164)=3.14,
P< 0.003; compared to patients without DD.
Approximately 30% of patients with DD said these
episodes occurred as part of their panic attacks, 20%
said they were dif ferent from panic, and 50% said both.
Finally, 90% of patients with DD reported that these
experiences were subjectively frightening.
DISCUSSION
DD episodes were common (71%) in this sample of
panic disorder patients. Similar to previous findings
[Cassano et al., 1989], there was also evidence to
suggest that panic patients who experienced DD were
younger and had greater clinical severity compared to
patients who did not report DD experiences. Further,
only approximately one-third of patients said these
episodes exclusively occurred as part of their panic
attack. Given that panic disorder is common in patients
with depersonalization disorder [Simeon et al., 1997],
further investigation of the presence of dissociative
conditions in panic patients who report depersonaliza-
tion outside of panic attacks appears warranted. The
majority of all patients who reported DD episodes
(90%) found these experiences frightening. The fact
that patients with DD had higher symptom severity
ratings for dizziness and for faintness, but not for more
arousal-based panic symptoms, suggests these types of
experiences may be more long-lasting and slower to
dissipate than more dramatic, but short-lived, cardio-
respiratory and other arousal types of symptoms.
To our knowledge, this study represents one of the
first attempts to develop and evaluate a measure
specifically designed to capture this phenomenology
in clinically anxious patients. To this end, a 28-item
self-report measure of DD with promising psycho-
metric properties is now available. The full version of
the scale is useful for assessing a broad array of DD
symptoms and future factor analytic studies with large
samples may be successful in delineating reliable
factors which can then translate into subscales. Alter-
natively, a brief version could be developed following
 Research Article: Depersonalization-Derealization Inventory
further psychometric research. We have tentatively
suggested that the 12 items with the highest severity
rankings may suffice. Regardless, by publishing the
DDI content in the public domain, we hope to
facilitate further study of this important topic. Aside
from panic disorder, it would be particularly interesting
to study DD in patients with posttraumatic stress
disorder, as there is some suggestion that DD is
pronounced in individuals exposed to life threatening
situations [Noyes and Kletti, 1977; Noyes et al., 1987].
The DDI may also prove useful in the assessment of
dissociative conditions such as depersonalization dis-
order. In this regard, the fact that measures of
dissociation were not included in the present investiga-
tion could be viewed as a limitation of the study.
REFERENCES
American Psychiatric Association. 1994. Diagnostic and statistical
manual of mental disorders (4th ed) (DSM-IV). Washington, D.C.:
APA.
American Psychiatric Association. 1987. Diagnostic and statis-
tical manual of mental disorders (3rd ed, revised)(DSM-III-R).
Washington, D.C.: APA.
Beck AT, Epstein N, Brown G, Steer R. 1988. An inventory for
measuring clinical anxiety: Psychometric properties. J Cons Clin
Psychol 56:893–897.
Beck AT, Ward CH, Mendelson M, Mock JE, Erbaugh JK. 1961.
An inventory for measuring depression. Arch Gen Psychiatry
4:561–571.
Brauer R, Harrow M, Tucker GL. 1970. Depersonalization
phenomena in psychiatric patients. Br J Psychiatry 117:509–515.
Cassano GB, Petracca A, Perugi G, Toni C, Tundo A, Roth M. 1989.
Derealization and panic attacks: A clinical evaluation on 150
patients with panic disorder/agoraphobia. Comp Psychiatry
30: 5–12.
Cox BJ, Norton GR, Swinson RP. 1992. The panic attack question-
naire-revised. Toronto, Canada: Clarke Instititute of Psychiatry.
Davison K. 1964. Episodic depersonalization: observations on 7
patients. Br J Psychiatry 110:505–513.
Derogatis LR, Lipman RS, Covi L. 1973. SCL-90: an outpatient
psychiatric rating scale. Preliminary report. Psychopharm Bull
9:13–25.
175
Edlund MJ, Swan AC, Clothier J. 1987. Patients with panic attacks
and abnormal EEG results. Am J Psychiatry 144:508–509.
Harper M, Roth M. 1962. Temporal lobe epilepsy and the phobic
anxiety-depersonalization syndrome. Part I: a comparative study.
Comp Psychiatry 3:129–151.
Hollander E, Liebowitz MR, DeCaria, C, Fairbanks J, Fallon B,
Klein DF. 1990. Treatment of depersonalization with serotonin
reuptake blockers. J Clin Psychopharmacol 10:200–203.
Marks IM, Mathews AM. 1979. Brief standard self-rating for phobic
patients. Behav Res Therapy 17:263–267.
Marshall RD, Schneier FR, Lin S-H, Simpson HB, Vermes D,
Liebowitz M. 2000. Childhood trauma and dissociative symptoms
in panic disorder. Am J Psychiatry 157:451–453.
McWilliams LA, Cox BJ, Enns MW. 2001. Childhood trauma and
depersonalization during panic attacks: A second look using a
nationally representative sample. (Letter to the editor). Am J
Psychiatry 158:656.
Miller PP, Brown TA, DiNardo PA, Barlow DH. 1994. The
experimental induction of depersonalization and derealization in
panic disorder and nonanxious subjects. Behav Res Therapy
32:511–519.
Norton GR, Dorward J, Cox BJ. 1986. Factors associated with panic
attacks in nonclinical subjects. Behav Therapy 17:239–252.
Noyes R, Kletti R. 1977. Depersonalization in response to life-
threatening danger. Comp Psychiatry 18:375–383.
Noyes R, Kuperman S, Olson SB. 1987. Desipramine: a possible
treatment for depersonalization disorder. Can J Psychiatry 32:782–
784.
Roth M. 1959. The phobic anxiety-depersonalization syndrome. Proc
R Soc Med 52:587–595.
Sierra M, Berrios GE. 2000. The Cambridge depersonalization scale:
a new instrument for the measurement of depersonalization.
Psychiatry Res 93:153–164.
Simeon D, Gross S, Guralnik O, Stein DJ, Schmeidler J, Hollander
E. 1997. Feeling unreal: 30 cases of DSM-III-R depersonalization
disorder. Am J Psychiatry 154:1107–1113.
Simeon D, Guralnik O, Gross S, Stein DJ, Schmeidler J, Hollander
E. 1998. The detection and measurement of depersonalization
disorder. J Nerv Men Disease 186:536–542.
Stein MB, Uhde TW. 1989. Depersonalization disorder: effects
of caffeine and response to pharmacotherapy. Biol Psychiatry
26:315–320.
Steinberg M. 1991. The spectrum of depersonalization: assessment
and treatment. In: Tasman A, Goldfinger SM, editors. American
Psychiatric Press review of psychiatry (Vol 10). Washington, DC:
American Psychiatric Press. p 223–247.