INSIDE-OUT MINDS:

CONSCIOUSNESS, ATTENTION, AND DEPERSONALIZATION

Patrick Mellor
San Francisco State University
December 20, 2015
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Abstract

Depersonalization disorder (DPD), which results in a specific impairment and

modification in the construction of self and representation of the body and external world, is

close to a model system to investigate the structure of phenomenal consciousness, but has been

almost completely neglected by philosophers of consciousness. This is due to persistent

misinformation on the nature of the disorder, an underestimation of its prevalence, and extreme

difficulty in accurately expressing and understanding the anomalous experiences of its sufferers

in the context of the technical language and pre-framed problems of philosophy of mind. Having

intimate and long-term personal experience of depersonalization, I hope to both clear up some of

this misunderstanding and give compelling reasons why the intensive study of this disorder is

imperative to gain much needed empirical information illuminating the relationship between

phenomenal consciousness, attention, and self-representation.

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INSIDE-OUT MINDS:
CONSCIOUSNESS, ATTENTION, AND DEPERSONALIZATION

Depersonalization has existed throughout history; different societies refer to the experience under

a range of names of ominous import. Referred to in Zen Buddhist literature as "falling into the

pit of the void," in early modern European mystical texts as "the dark night of the soul," and seen

by diverse contemplative traditions as a stage in the realization of non-duality of self and world,

it consists of a deeply fundamental modification in the structure of phenomenal consciousness.

Much of the neglect of DPD in current psychology, psychiatry, and philosophy of mind stems

from over-complication of the symptoms and causes of the disorder, and attempts to causally

relate it to very different mental health problems such as post-traumatic stress disorder (PTSD),

and the various dissociative disorders. The onset of DPD is certainly correlated with traumatic

experiences in some cases, but it is a stable alteration of the structure of consciousness

independent of the other symptoms associated with psychological trauma, and often persisting

long after these have resolved, in some cases for decades. DPD differs from the dissociative

disorders in that it involves no objective disturbance of memory or personal identity, and none of

the cognitive fragmentation associated with these disorders (fugue states, dissociative amnesia).

DPD is strongly correlated with anxiety disorders, but the core experience of depersonalization

often persists long after these have resolved; usually DPD only abates through insight and

acceptance of its symptoms, and a cognitive integration which can often be psychologically

beneficial, when it occurs.

Much of the neglect of DPD in both academic and popular culture is due to an inability of

non-sufferers to empathize with its symptoms, even though many people have experienced them

transiently and in a mild form, for instance when repeating a word until it sounds unfamiliar.
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Sufferers of DPD, lacking the ability to express their experiences in language, employ

metaphorical constructs in an effort to convey meaning. This leads to problems because their "as

if" language leads to a misinterpretation of their symptoms as a more familiar form of emotional

or existential crisis, and a lack of understanding of the bizarre and often horrifying nature of their

experiences. But DPD is a quite different state of mind from existential anxiety. Unlike most

mental illnesses, DPD usually has an extremely sudden onset, for some people almost

instantaneous, and often uncorrelated with any specific trigger, although some drugs, particularly

marijuana, when combined with previous traumatic experiences, seem to precipitate it in some

cases. Most sufferers describe its onset in terms of an utterly alien state of mind suddenly

descending upon them, along with a form of fear they have never before experienced, and a

perceived experience of death, which sometimes persists and leads to depression and emotional

withdrawal. Because DPD strikes at the core of our conception of consciousness, the self, and

our relation to the external world, it leads to anxiety even among non-sufferers, who are quick to

categorize it as a symptom of other disorders, lacking the ability to empathize with or

contextualize the experiences of depersonalized people. This problem is compounded by the

unfortunate choice of the term "depersonalization" to describe the experience, a word that

already has a more familiar meaning as something that is done to people by various oppressive

political and exploitative elites, which leads to the assumption that DPD is the consequence of

such oppression, when it is an entirely unrelated phenomenon. DPD is usually discussed in

comparison to derealization, a sense of unreality regarding the external world, although the two

are intimately linked and are simply different perspectives on the same underlying condition.

The underlying psychological change in DPD is a reorientation of phenomenal

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consciousness such that it becomes capable of doubting its association with a self, and a

Cartesian style separation of res cogitans from res extensa, a dis-identification of consciousness

with the body. The persistent doubt that phenomenal experience entails the existence of a unitary

subject of experience (a self), results in a dramatic change in the representation of self in the

world. These doubts are experienced on a fundamental, experiential level; they are not existential

ruminations or thoughts, but lie on a substrate underlying cognition, and strongly correlate with a

specific set of perceptual changes, analogous with modifications of Kantian intuitions, such that

the depersonalized person inhabits a very different experiential world. My use of the word

"doubt" above is not an adequate way of describing the depersonalized state, but it is very hard,

if not impossible, to employ linguistic terms to describe the experience, and "doubt" captures the

core feature of depersonalization, that, despite these changes, reality testing is not changed, in

contrast to psychosis, and these internal changes do not result in any externally observable

impairments or delusional states. This is what leads to the commonly misunderstood "as if"

statements of sufferers. DPD is useful as a probe for some of the core problems of philosophy of

mind and cognitive neuroscience, because it specifically impacts phenomenal experience, self-

representation, and representation of the external world, while leaving other areas of cognition

unaffected. DPD can thus be used as a model disorder to examine the phenomenological

structure and neurological correlates of these systems.

The fundamental changes in the structure of consciousness in DPD lead to perceptual

changes, often described as derealization. Many of these changes involve the visual system.

Sufferers describe a veil or barrier between themselves and their visual experience of the world,

a flattening of visual perception into a two-dimensional state, and the intrusive presence of
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"floaters" in the visual field.(tissue fragments trapped in the developing eye under the cornea,

which we all possess but which are usually filtered out of our experienced vision). Their visual

perception is also redirected toward the periphery, sometimes with a blurring of the central

portion of the visual field; alternately a form of "tunnel vision" can occur. The 2D flattening of

vision leads to misinterpretation of cues regarding the size and distance of objects, often referred

to as a "dolly zoom" effect (a special effect used in cinema), and a sense of the visual field as

pressed against the eye, leading to claustrophobia. Intrusive irregularities and fluctuations in the

visual field as a whole, often described as "static," or "visual snow," also frequently occur.

Depersonalized people often describe these symptoms as correlating with or resulting from a

withdrawal of consciousness from visual perception, describing this as an experience of looking

out at the world from within their own skull, somewhere behind the eyes. By far the most

popular result in an online image search for "depersonalization disorder" is a drawing of a

homunculus sitting in a chair observing the world through a mechanical eye. Sufferers of DPD

often have trouble reading, driving, and performing other visually demanding activities as a

result of these symptoms, but report that their sensitivity to minute changes in their visual field is

actually enhanced, along with a focus on minute features to the detriment of seeing larger scale

patterns. They also report a diminution of perceived solidity and temporal stability of perceptions

of objects.

Regarding auditory perception, DPD is associated with a general sense of acoustic

muffling, but most of the specific changes involve linguistic experience. There is a separation of

the experiences of the sounds of words from the meanings of those sounds, and in the case of

visual descriptions, from the objects referred to by words. All these faculties still function, but
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they are no longer experienced as an integrated whole, the person simultaneously experiences an

understanding of the words with a sense of hearing alien, meaningless sounds. Proprioception is

also altered, people experience a sense of mechanically controlling their body as one would a

robot, and are hyper-conscious of complex details of muscular movement in simple tasks, to the

detriment of the task itself. When body movements are combined with visual observation of the

body, people report a strong sense of automation. This is one of the most unsettling symptoms of

depersonalization; best described as a lived experience of epiphenomenalism, and can persist for

long periods of time. The experience is of being a detached observer of one's own body, having

no sense of agency in directing its movement, actions, and often even speech, while the body

goes about its business much as before; often depersonalized people remain quite functional in

the world, so much so that their condition is invisible to outside observers.

These perceptual symptoms are usually accompanied by a feeling of detachment from

emotional experience, which feels flattened and "as if" it refers to another person, often to the

same person pre-depersonalization, who they sometimes describe as having died. Even with this

detachment, most of the time sufferers remain emotionally connected to others, it is their internal

experience of emotion that has changed, often along with a diminution of reaction to pleasurable

and unpleasant situations, stimuli, and activities they previously enjoyed.

Usually, for a person to recover from DPD, they must leverage the core experience of a

fundamental change in the structure of their consciousness into a commitment to achieve

understanding of what has happened without fear, repression, or diminution of its validity and

importance. Practices from traditions that recognize the value of such experiences, and provide

road-maps to use them to achieve a beneficial change in their state of mind, can be extremely
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helpful. Often people report improved mental health and integration following recovery from

DPD than they had before, once they accept that they cannot "unlearn" the condition, and find a

way to reduce anxiety and explore the many startling and beneficial insights that can eventually

be gained from an initially hellish experience. Societies that recognize the occurrence of DPD as

a stage in the psychological development of some people, particularly when they engage in

meditation and other contemplative traditions (for example, in some Buddhist traditions, where

DPD is known as "enlightenment's evil twin"), have a better support system for sufferers than

those that relegate the condition to an obscure and nebulous psychiatric diagnosis often

misunderstood and misdiagnosed by mental health professionals themselves. If DPD is correctly

diagnosed and recognized, pharmacologic treatment can be of great help in assisting the process

of integration, lamotrigine is currently one of the most promising drugs for this.

I argue that the core symptoms of DPD result from a modification in the regulation of

attentional systems, and in their relationship with consciousness. Specifically, that DPD gives an

informative perspective on what happens when top-down directed attentional systems specialized

for focus on external events are applied interoceptively, as opposed to the usual interoceptive

system, which is distinctly suppressed in DPD. Neuroimaging studies have already shown that

DPD correlates with anomalies in many brain systems connected with attention. For example,

strong pre-frontal activation, well known to correlate with top-down directed attention to

external tasks and events, has been shown to occur anomalously in people with DPD when their

brains are in a resting state, along with reduced activity in the default mode network (DMN).

Sierra and David (2011), observing that "it has been proposed that depersonalization is caused by

a fronto-limbic (particularly anterior insula) suppressive mechanism – presumably mediated via

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attention," performed "functional neuroimaging and psychophysiological studies [supporting] the

above model and [indicating] that, compared with normal and clinical controls, DPD patients

show increased prefrontal activation as well as reduced activation in insula/limbic-related areas. .

.it is likely, as suggested by some studies, that parietal mechanisms underpin feelings of

disembodiment and lack of agency feelings." Reduced activity of the anterior insula, which

integrates interoceptive and exteroceptive sensory information and is associated with emotional

coloring of this information, could specifically relate to the emotional detatchment from the body

seen in DPD sufferers. Lin (2015) argues that "the AIC [anterior insular cortex] is. . .the correlate

of the integration of exteroceptive and interoceptive signals and that it plays a role in maintaining

a salience network for the relevant states," and that in DPD, "the hypoactivity of the AIC leads to

the failure to associate affective significance with bodily states."

By "parietal mechanisms," Sierra and David are specifically referring to the right angular

gyrus (RAG), which is already known to be involved in the integration of intention to move and

experienced physical movement. They found that "an abnormally increased activation in the

angular gyrus of the right parietal lobe. . .correlated (r = 0.7) with ratings of depersonalization

intensity." The RAG is thought to perform an initial "bottom-up" comparison of exteroceptive

and interoceptive information by a mechanism of "predictive coding," where discrepancies in

predicted (computed by the RAG) and actual observed movements are noted, correlating with

conscious experience of these discrepancies. Sierra and David argue that "It is likely that the

experience or observation of movements which do not feel as arising from the self elicits an

attentional orientation response, similar to that elicited by unexpected events." According to

Ciaramelli et al. (2008), "the inferior parietal cortex, including the supramarginal gyrus and the
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AG, is part of a “bottom-up” attentional subsystem that mediates the automatic allocation of

attention to task-relevant information." In other words, overactivity of the RAG correlates with

increased, visually mediated, "bottom-up" attention toward the movements of a person's own

body. I argue that, as the prefrontal (top-down) attentional system is preoccupied with

suppressing certain limbic areas (such as the anterior insula), and examining interoceptive

information, this leads to a reduction in the sense of conscious agency regarding body

movements which is usually correlated with "top-down" attention directed toward the position of

the body in external space. This also correlates with the preponderantly visual nature of the sense

of loss of "ownership" of the body in DPD. Simply put, DPD is correlated with a reversal of the

usual relationship between top-down and bottom-up attention in reference to interoception and

exteroception. Top-down attention is redirected toward observing internal processes of

perception, and suppressing brain areas that would usually integrate these with external

perceptions. This leaves bottom-up attention to "take up the slack" regarding exteroception,

correlating with increased activity of parietal areas including the RAG, and a modified

experience of the external world, space, and time.

An important result showing that DPD is accompanied by a modified form of

interoceptive attention, as opposed to a simple inhibition or lack of body awareness, comes from

a study of heartbeat awareness in DPD sufferers. Michal et al. (2014) predicted that awareness of

heartbeat would be impaired in people with DPD, arguing that "results from neuroimaging

studies, though rare, show reduced activation of the insular and the anterior cingulate cortex in

response to aversive affective stimuli in DPD patients as compared to healthy controls. . .[T]he

insular cortex is responsible for the representation of visceral sensations accessible to awareness.
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Its activity correlates strongly with interoceptive awareness as measured by heart beat detection

tasks." They were surprised to find no evidence of reduced interoceptive awareness in DPD,

finding that "DPD patients performed similarly to healthy controls on the two different heartbeat

detection tasks, and they had equal scores regarding their self-rated clearness of body perception.

There was no correlation of the severity of ‘‘anomalous body experiences’’ and depersonalization

with measures of interoceptive accuracy." The authors concluded that their "main findings

highlight a striking discrepancy of normal interoception with overwhelming experiences of

disembodiment in DPD. This may reflect difficulties of DPD patients to integrate their visceral

and bodily perceptions into a sense of their selves." I would clarify this by adding that there is a

great difference between "equally accurate" and "normal," arguing that DPD sufferers are using a

different attentional system to achieve the same accuracy as the controls in this study.

This modified form of interoception is not connected to introspection, self-objectification,

or any such conscious process. Michal et al. argued that "another cause of impaired interoception

in DPD patients may be their increased self-focused attention. Recently it has been shown that

self-focused attention, which is considered as crucial factor for the maintenance of

depersonalization, correlated inversely with the sensitivity toward one’s cardiac signals." The

paper they refer to for this result (Ainley and Tsakiris 2013) uses the term "self-objectification"

whereas Michal et al. write "self-focused attention." Ainley and Tsakiris specifically refer to self-

objectification of women in patriarchal societies leading to eating disorders, and never mention

"self-focused attention." This underlines firstly, that many ill-defined words are thrown about

attempting to describe the depersonalization experience, and secondly, that the type of "self-

focused attention" seen in DPD is not a conscious process (which may or may not result in
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impaired interoception), but a result of a reorientation of unconscious attention. This gives

evidence for a degree of dissociation between consciousness and attention, both in DPD and

more generally.

Suppression of the normal interoceptive system in DPD is not accompanied by

measurably impaired interoception because top-down (prefrontally mediated) attention

compensates for and replaces it. Although deficits of interoceptive awareness are not seen,

conscious experience of the body is heavily modified, as the form of attention now directed

toward interoception is strongly associated with phenomenal consciousness of outside events

(although still separable from it). People with DPD develop anomalous consciousness of their

internal states, and of the boundary between interoception and exteroception, as well as a

separation between consciousness and self-representation. Prefrontally mediated attentional

systems also have increased access to low-level internal processing of sensory information,

which is usually opaque to conscious awareness, and bottom up processes take over to manage

attention toward external events (which include visual observation of the body). Because usually

externally directed attentional systems are observing internal states, they become perceived as

external events, leading to phenomenal alienation from the body.

The consequences of this attentional shift regarding visual perception of external events

can be seen experimentally if the RAG is artificially stimulated, mimicking its increased activity

in DPD. Blanke et al. (2002) famously discovered that "'Out-of-body' experiences. . .curious,

usually brief sensations in which a person's consciousness seems to become detached from the

body and take up a remote viewing position [could be repeatedly induced] by focal electrical

stimulation of the brain's right angular gyrus. . .Stimulation at this site also elicited illusory
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transformations of the patient's arm and legs (complex somatosensory responses) and whole-

body displacements (vestibular responses)." In addition to this empirical evidence of the

phenomenal effect of RAG stimulation, a study by Muggleton et al. (2011) showed that, in a

visual task measuring the speed of discrimination of a pop-out feature in a visual field (a test of

bottom-up attention), stimulation of the RAG "[reduced] reaction time costs on switch trials and

[sped] responses when the color of the pop-out target switched. . .These results provide evidence

for an attentional reorienting mechanism, which originates in the rANG and is modulated by the

implicit memory of the previous trial. The rANG plays a causal role on switch trials during

priming of pop-out by interacting with visual processing." In contrast, some of the same authors

reported in another paper (Muggleton et al. 2008) that stimulation of the RAG reduced

performance in a visual task involving a search for specified conjunctions of objects (a top-down

task).

The consequences of this attentional reorientation have been examined in more detail by

Adler et al. (2014) in their paper "Altered orientation of spatial attention in depersonalization

disorder," and I argue that, when combined with what we know about the neurological correlates

of DPD, and the details of its phenomenal experience, this study has great importance in

elucidating the ways DPD differs from normal consciousness, and shedding some light on the

relationship between consciousness and attention. The study aimed to clarify whether previous

observations of subtle impairments in tasks requiring use of short term memory and selective

attention in DPD, specifically Guralnik et al. (2007), were due to changes in memory encoding

or attentional systems. Adler et al. used two spatial cuing tests. In the first test (detection)

participants were asked to press a button when they saw a Garber patch (which had either
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oblique or vertical stripes) on either the right or left side of a screen. In the second test

(discrimination), participants were asked to only press the button when they saw the oblique

striped patch. In both tests, presentation of the patch was preceded by an arrow in the center of

the screen pointing right or left, or neutral arrows pointing both ways. 70% of the time the arrow

was accurate, and indicated the side of the screen on which the patch would appear, 15% of the

time a neutral double arrow was shown, and in the remaining 15% of trials an incorrect arrow

appeared. A group of people with DPD performed both tasks, along with a control group. Both

groups were accurate in their responses roughly 95% of the time in both tests. In the detection

test, a neutral arrow increased their reaction times by about 20ms, rising to 40ms with a wrong

arrow. There was no significant difference between the groups. This makes sense; in the

detection test, the total reaction time cost is simply the time taken redirecting attention to the

correct side. The arrow is correct 70% of the time, so it makes sense to expect it to be correct. A

neutral set of arrows does not direct attention to either side of the screen, so the reaction time

cost should be simply the time usually taken to direct attention to one side of the screen in the

interval between the arrow and presentation of the image. An incorrect arrow should lead to

double the cost of the neutral arrows, as was seen, because it directs attention to the wrong side

of the screen, rather than the center.

In the discrimination test, the DPD group's reaction time increased by roughly 20ms with

a neutral arrow, rising to 45ms with a wrong arrow, similar to the detection test. The control

group's reaction time also increased by 20ms with a neutral arrow, but with a wrong arrow their

total reaction time increased by 60ms over the correct arrow. The wrong arrow caused nearly

double the reaction time delay in the control group that it did in the DPD group. In contrast to
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Guralnik et al.'s study, the DPD group had a clear advantage in this test. The main question from

this experiment is: Why does the wrong arrow have a greater negative effect on reaction time

than the positive effect of the right arrow in the controls but not in the DPD group? This task

required the participants to perform two steps: to detect an image on the right or left side of the

screen, and then to determine the orientation of its stripes, before pressing the button. The

increased reaction time cost of the wrong arrow has been seen in many similar studies, and

reflects the goal directed, top-down attention the participants apply to the test. They are focusing

on the side referred to by the arrow, ready to discriminate the stripe pattern when the image

appears. They are not simply waiting for an image, as in the previous test. This two step process

requires a two step disengagement and reorientation if the arrow is incorrect, as is reflected by

the double reaction time cost over the detection test in the control group.

The DPD group did not show any significant additional time cost between the two-step

test and the one-step test; this is quite strange. We would expect that some kind of additional

processing, taking time, would be occurring in the two step test. The authors argue that in the

"Spatial Cueing paradigm the informative cue leads to a top-down guided attentional shift to the

predicted location, whereas the invalid cued target induced a bottom-up, i.e. a sensory driven

capturing of attention to the opposite side." They then infer that that the DPD group were better

able to shift their attentional focus to the correct side due to an increased speed of bottom-up

attentional redirection compared to the control group, correctly noting that "DPD patients may

have a relative preponderance of the bottom-up mode of attentional regulation as reflected by

increased responsiveness to unexpected events." I agree with them, but also argue that the DPD

group's improved performance in this test is due to a greater separation between the two modes
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of attention. The bottom-up system's dissociation from the top-down system is just as important

as its relative strength; the top-down system may be less directly involved in the task, but it is

certainly not idle; it is viewing the situation "from afar" or paradoxically, "from within." The

DPD group have an entirely different mode of attentional regulation to the control group, to put a

difficult concept crudely, their attentional systems are, to a greater or lesser degree "inside-out,"

compared to the controls. Again clarity of definition is important here, by bottom-up attention, I

am in no way referring to reflexive reactions. By top-down attention, I do not mean "the goal

seeking self." It is easy to become mired in confusion here without keeping this in mind.

While the above experiment may seem very simple and contrived, I feel it illuminates

something of the central paradox of depersonalization, while integrating some of the

neuroscientific description of the condition with the experienced state. Depersonalized people

feel a simultaneous hyper-awareness and lack of control of their bodies. Their bottom-up

attention to tasks reflects a general bottom-up orientation to the world. The conscious subject

becomes mired in a strange country of neural and bodily processes that are usually automatic.

Because they are automatic, and usually opaque to conscious examination, this leads to a

sensation of "viewing a robot," or "watching through a screen." A good example of this is the

"Dolly Zoom effect," this experience of visual objects increasing and reducing in size relative to

their background happens because the person is conscious of the visual system attempting to

specify the size of an object, fixates on this bizarre experience, and interferes with its resolution.

To the degree that it is possible, this person is conscious of (represents) the process of her visual

system constructing a 3D visual representation. Note the paradox here, and the implications for

Metzinger's correct observation that "fully transparent phenomenal representations force a

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conscious system to functionally become a naïve realist with regard to their contents: whatever is

transparently represented is experienced as real and as undoubtedly existing by this system"

(Metzinger 2003). Concentration on visual and auditory minutiae, awareness of usually

autonomic movements, auditory distortions and a sense of strangeness to language, all correlate

with the same anomalous regulation of attention. DPD is actually characterized by consciousness

reaching down, not automation reaching up. The processing the person becomes aware of cannot

be integrated seamlessly into consciousness, even though it becomes viewable by "the mind's

eye." This leads to a situation best characterized as the direct experience of an epiphenomenal

dualism, but the self as seen by a depersonalized person is very different from what most of us

experience the majority of the time. Immersion in decontextualized long term memories, and a

sense of temporal scrambling commonly occur. This is again because we are "viewing the

machinery." Depersonalized people do not doubt that they have phenomenal experiences, they

doubt that these experiences are unified into a self that is mapped onto the body. The Cartesian "I

think, I exist" becomes instead the unitary, unspeakable, experience of phenomenal

consciousness. It is hopefully clear how the clumsily termed state of "depersonalization," can be

a step toward more euphoric and insightful experiences of non-duality.

I hope that in this paper I have suggested some directions that could be taken in

researching the relationship between consciousness and attention by examining one of the most

dramatic examples of what happens when this relationship goes awry. Examining the details and

consequences of the reorientation of the top-down attentional system in DPD could allow much

insight into its usual functioning, through analysis of the specific perceptual alterations observed

in DPD, and of the relationship between different forms of attention, phenomenal consciousness,
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and the experience of self. There are many implications here for HOT theories of consciousness,

and the precise role and position of self-representation in phenomenal experience.

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References

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Ainley, V. & Tsakiris, M. “Body Conscious? Interoceptive Awareness, Measured by

Heartbeat Perception, Is Negatively Correlated with Self-Objectification.” PLoS ONE,

8(2) (2013): e55568. doi:10.1371/journal.pone.0055568

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419 (2002): 269-270.

Farrer, C. et al. “The angular gyrus computes action awareness representations.” Cerebral

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(2014): e89823. doi:10.1371/journal.pone.0089823.

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