Depersonalization-derealization disorder in men

The objective: to analyze the features of the course of depersonalization-derealization disorder (DDD) in men on the example of a clinical case. Materials and methods. The pilot study included 51 individuals, namely: 8 (15.7%) men and 43 (84.3%) women, with average age 21 years (SD=3.66) and 23.86 years (SD=6.88), respectively. Study participants had criteria for DDD according to the International Classification of Diseases for Mortality and Morbidity Statistics 10th revision (ICD-10). The following tests were used in the research, such as the Hamilton Anxiety Rating Scale (HAM-A), the Beck Hopeless-ness Questionnaire (BHI), the Sheehan Patient Rated Anxiety Scale (SPRAS), the Cambridge Depersonalization Scale (CDS), and the Dissociative Experiences Scale (DES). Statistical data analysis was carried out using the IBM SPSS Statistics program. Results. Depending on comorbid pathology, three groups of participants were formed: 1) without comorbid pathology; 2) with comorbid depressive disorders; 3) with anxiety disorders. Two men were found to have cannabis-induced DDD. The article presents one typical case of cannabis-induced DDD. A statistically significant difference was determined between men and women who have higher scores on the Dissocia-tive Experiences Scale DES (p=0.032). Several correlations between the CDS and Beck tests, as well as the Beck and Hamilton tests (men T b =0.571; p=0.01) were found only in men. Conclusions. These cases have a high comorbidity, especially with anxiety disorders. Further research is needed to confirm this correlation. The specific weight of depersonalization-derealization symptoms according to the DES scale is significantly higher in men. Cannabis-induced DDD is more common in men than women. At the same time, no socio-demographic differences between the sexes were found.

D epersonalization and derealization disorder (DDD)   belongs to the group of dissociative disorders and occurs with a frequency of 1.8-2% in the general population [1,2].Despite the previously held belief that dissociative manifestations are more common in women, men and women are equally susceptible to developing DDD [3].DDD most often affects young people, with an average age of onset of 16 years [4,5].
Given the significant bias in the study of dissociative phenomena toward women, men's characteristics have hardly been studied.
Before the late 19th century and early 20th century, dissociative phenomena were attributed only to women and called «hysteria».Separately described cases of dissociative manifestations in men were ignored by the medical community [6].Jean-Martin Charcot and his student Sigmund Freud were not the first who questioned the established views that hysteria is an exclusively female disease, but they made a significant contribution to the revision of this issue [7].In the 20th century, hysteria began to be associated with traumatic experiences, and there were so many cases of dissociation in men, especially soldiers on the battlefield, that the issue was no longer in doubt [8].
From modern achievements, we know that male gender is one of the risk factors for posttraumatic stress disorder with dissociation symptoms [9].A study on the gender difference in peritraumatic dissociation and distress and the prediction of acute stress disorder among victims of violent crime found that high levels of peritraumatic dis-tress and traumatic experiences in the past are risk factors for the development of this disturbances in men [10].
Considering DDD, the etiological causes are still unknown [11].There are three main models that explain the emergence of dissociative disorders, including DDD: the post-traumatic model, the socio-cognitive model, and the transtheoretical framework [12,13].
We have already mentioned the post-traumatic model above; it was substantiated in the 20th century and for a long time was the only explanation.Despite of the fact that correlation between dissociation and trauma is strong, the post-traumatic model still has serious gaps [14][15][16].
In the 1980s, in contrast to the post-traumatic model, the socio-cognitive, iatrogenic and fantasy models emerged, denying the existence of dissociative processes as such and explaining this by the hypnotic nature of patients, their tendency to fantasies on socio-cultural influences, since at that time and still today, dissociative disorders are the subject of many stories in the media [17].The transtheoretical framework considers dissociation as a disruption of normally adaptive systems and functions, and takes into account potentially interacting variables: sleep disturbances; impaired self-regulation and inhibition of negative cognitions and affects; hyperassociations and recruitment shifts; and deficits in testing reality [18,19].
In addition, depersonalization/derealization can be artificially induced by the use of dissociative drugs -NMDA receptor blockers, such as ketamine, dextromethorphan or phencyclidine [20].There are many cases of DDD induced by certain medications and recreational drugs, most often cannabis [21,22].Cannabis-induced DDR is most common in males and adolescents, especially those with a history of anxiety disorders [23].
Given the significant bias in the study of dissociative phenomena towards women, the peculiarities in men have hardly been studied.
The objective: to analyze the features of the course of DDD in men on the example of a clinical case.

MATERIALS AND METHODS
We performed a pilot study with 51 outpatients at the Department of Psychiatry, Psychotherapy and Medical Psychology of Shupyk National Healthcare University of Ukraine in 2023.These included 8 (15.7%) men and 43 (84.3%)women; all participants were young Ukrainian civilians (18-44 years old).
In order to participate in the study, participants had to meet the following criteria (a) have a high score on the Cambridge Dissociative Disorder Scale (cut-off ≥ 70); (b) be over the age of 18; (c) have symptoms that met the criteria for DDR according to the International Classification of Diseases for Mortality and Morbidity Statistics, 10th Revision (ICD-10).They were excluded if they had a past or present psychotic episode, organic brain disorder, substance use less than 3 months before participation in the study, or traumatic brain injury.
In addition to the socio-demographic study and diagnosis according to the ICD-10 criteria, patients' mental state was assessed using the following: Hamilton Anxiety Rating Scale (HAM-A), Beck Hopelessness Inventory (BHI), Sheehan Self-Rating Anxiety Scale (SPRAS), Cambridge Depersonalization Inventory (CDS), Dissociation Scale (DES).Statistical analysis of the data was performed using IBM SPSS Statistics.

RESULTS AND DISCUSSION
Descriptive analyses were first performed using mean scores and standard deviations (SD) (Table 1).
It is important to emphasize that two of the 8 men had cannabis-induced DDD, while no women attributed the onset of DDD to psychoactive use.
According to Shapiro-Wilk test ration scales do not correspond to the normal distribution of data.Nonparametric tests were used for calculation: Kruskal-Wallis and Kendall's Tau correlation.Statistically significance was established at p<0.05.
There is statistically significant difference between the men and women having higher scores in dissociative subscale of DES (p=0.032)(Table 2).There are no significant differences in other tests score between the sexes.
Also there in significant negative correlation between DES scores and age (male T b = -0.617;p=0.002; female T b = -0,209; p=0.047).Also correlation between HAM-A and BHI tests scores in men is found (T b =0.571; p=0.01), but isn't detected in women.
Here presented the clinical case as an illustration of several tendencies that were identified in the study.It's an example of cannabis-induced DDR and panic disorder in a man of working age:

Clinical case
A, 22 years old man, asked for help due to periodic panic attacks and a constant feeling of unreality of the world around him.Since the age of 20, he had been using marijuana from time to time, and in the last year almost daily.Against the background of constant use of cannabinoids, A. began to notice transient changes in consciousness that lasted several minutes and occurred in response to any external stimulation: excessively sweet or strong tea, cigarette smoking, intense physical activity, lack of sleep.These feelings were not intense and long-lasting, so they did not cause discomfort.
The transient states of depersonalization lasted for several months until the patient experienced a panic attack induced by marijuana use: he was afraid of the state of altered consciousness; he thought he was «losing his mind».After this episode, the depersonaliza-

Research criteria
Men, n=8

Women, n=43
Age (mean, SD) 21 (SD=3.66)tion\derealization became constant and frightening.A. also had occasional panic attacks when depersonalization and derealization feelings intensified, and felt as if he was losing control of his consciousness.
Test evaluation shows: DES score -18.57(normal, cut-off ≥30); depersonalization subscale of DES -60 (cutoff ≥30); CDS -75 (cut-off ≥70); BHI -24 (moderate depression); HAM-A -15 (normal); SPARS -35 (clinical anxiety).The state of depersonalization and anxiety disorder had a significant impact on the quality of life: the patient stopped going to the gym, his academic performance deteriorated, and he gave up his romantic relationship with his girlfriend.
Because of pilot version of this study the male group isn't big enough.Moreover, the low representation of men in this study can be explained by the general tendency of men under 50 to visit medical specialists less often than women of the same age group [24][25][26].
All subjects were divided into three groups: those with isolated DDD, comorbid DDD with anxiety disorder or depressive disorder.Men most often fell into the group of DDD with comorbid anxiety disorder, while in women this group is the smallest.

CONCLUSIONS
Men with DDD seem to be less likely to seek medical help, of all the respondents, the proportion of men is 18.6%.Detected cases in men are highly comorbid, especially with anxiety disorders.Longitudinal assessment is necessary to confirm this correlation.The specific weight of depersonalization-derealization symptoms in the DES scale is significantly higher in men.
Cannabis-induced DDD is more common in men rather than in women.None social-demographic difference between sexes was found.

Table 1
Profile of the Participants and Gender DifferencesNote.* -p<0.05.