Depersonalisation Disorder

Depersonalisation Disorder

Depersonalisation Disorder

Depersonalisation disorder involves an unpleasant, chronic and disabling alteration in the experience of self and environment. In addition to these classic features of depersonalisation and derealisation, symptoms may also encompass alterations in bodily sensation and a loss of emotional reactivity. Primary depersonalisation disorder is probably more common than previously thought, and here we discuss the diagnosis, assessment and treatment of the condition, with particular reference to our experiences in a specialist depersonalisation clinic. We also consider psychological and biological aspects of the condition. Although there is as yet no recognised treatment for this disorder, various pharmacological interventions, particularly a combination of lamotrigine and a selective serotonin reuptake inhibitor, have shown promise. We discuss these drug treatments, together with psychological approaches, in particular, a recent cognitive behavioural conceptualisation and treatment approach.

Symptoms:

    1. Feeling detached from one’s mental processes or body

    1. Intact reality testing

    1. Clinically significant distress and/or functional impairment

  1. Symptoms do not occur exclusively as part of another disorder or due to direct physiological effects of a substance

Self-reports emphasise the strange and disturbing quality of the depersonalisation experience: some patients report feeling ˜like a robot, different from everyone else and separate from myself (this last should be understood metaphorically rather than taken to imply autoscopic experience). Others describe feeling half-asleep or as if my head is full of cotton wool, with associated difficulties in concentration. External reality may also be strangely altered: it may appear somehow artificial as if painted, not natural, or two-dimensional or as if everyone is acting out a role on a stage, and  just a spectator. Even though the world does not necessarily look unreal, it is nevertheless experienced as less interesting and less alive than formerly.

A reduction in, or complete absence of, bodily feelings is often described (as if I were a phantom body, my hands seem not to belong to me), as are reduced intensity in the experience of thirst, hunger and physical pain. Another frequent theme is a reduction or loss of emotional responses: my emotions are gone, nothing affects me, I am unable to have any emotions, everything is detached from me. This loss of emotional reactivity may be particularly disturbing for the patient and those around them, and can have serious adverse effects on intimate relationships.

Causes:

Depersonalisation may occur as a transient phenomenon in healthy individuals, particularly in the context of fatigue, during or after intoxication with alcohol and/or drugs, or in situations involving serious danger (Noyes & Kletti, 1977). It may also occur as a chronic, disabling and clinically significant phenomenon, either as a primary disorder or secondarily in a range of neuropsychiatric settings (e.g. major depressive disorder, schizophrenia, temporal lobe epilepsy). Until recently, there was a prevailing consensus that the number of individuals who experience this disorder in a pure or isolated form is small. More commonly, depersonalization-derealization phenomena occur in the context of depressive illnesses, phobic disorder, and obsessive-compulsive disorder(World Health Organization, 1992: p. 172).

Mayer-Gross (1935)conceived of depersonalisation as a pre-formed response of the brain meaning that he believed it to be a normal response to threat which could become fixed and maladaptive in some individuals. Seventy years later, this remains an attractive idea. Healthy individuals exposed to life-threatening danger almost always report at least some features of depersonalisation (Noyes & Kletti, 1977), supporting the idea that it is a normal part of the response to overwhelming threat. It may be that in susceptible individuals this response is more readily triggered and that, once established, depersonalisation becomes fixed and pervasive. Both psychological (Sedman, 1970) and biological (Sierra & Berrios, 1998) models suggest that, in depersonalisation, normal emotional responses are shut down, leading to de-affectualisation with associated loss of emotional tone in the experience of oneself (depersonalisation, desomatisation) and one’s surroundings (derealisation). Once established, the unpleasant and unfamiliar feelings and experiences that comprise the depersonalisation symptom complex may in turn generate further anxiety, and so on in a vicious cycle. This may be the basis of the relationship between depersonalisation and anxiety seen in some patients, as mentioned above, and it forms the cornerstone of a recent cognitive behavioural conceptualisation (Hunter et al, 2003).

Treatment:

There is no recognised drug treatment for depersonalisation, and at the time of writing no drugs are licensed for its treatment in the UK. However, there is some evidence to support the use of selective serotonin reuptake inhibitor (SSRI) antidepressants.

There is no recognised psychological treatment for depersonalisation. There are isolated case reports describing successful treatment using psychoanalytical therapy (Torch, 1987), behavioural therapy (Sookman & Solyom, 1978) and directive therapy (Blue, 1979), although in the latter two reports the patients described have high levels of comorbid psychopathology and may not be cases of primary depersonalisation.

More recently, a cognitive behavioural model of depersonalisation has been proposed (Hunter et al, 2003). It is based on the idea, touched on earlier in this article, that anxiety and depersonalisation are intimately related, and that depersonalisation is best conceptualised as related to anxiety disorders rather than to dissociative conditions.

Relaxation techniques such as progressive muscular relaxation do not appear to be of benefit in depersonalisation. Indeed, it has been noted that patients with depersonalisation may actually experience an increase in symptoms after using progressive muscular relaxation (Fewtrell, 1984). However, techniques aimed at refocusing attention away from introspection and self-observation may yet prove to be of benefit, and to this end the use of biofeedback methods may be a worthwhile avenue for future study.

    1. Regarding treatment for depersonalisation disorder:

        1. there are well-established treatment guidelines

        1. olanzapine is usually helpful in reducing symptoms

        1. fluoxetine has recently been shown to be effective in depersonalisation

        1. CBT may have a role

      1. clonazepam is useful in some patients.

  1. Regarding the use of lamotrigine in depersonalisation disorder:

      1. randomised controlled trials have confirmed its efficacy

      1. Stevens Johnson syndrome is a recognised adverse effect

      1. haematological and biochemical indices should be monitored

      1. lamotrigine may be more effective when given with an SSRI

    1. lamotrigine may interact adversely with sertraline.

While depersonalization can be frightening, it isn’t necessarily harmful. Realizing that you don’t have some major neurological problem or serious mental illness can be very reassuring, and may help you cope with depersonalization.

  • Read about the condition. A number of books are available that discuss why depersonalization occurs and how to cope with it.
  • Join a support group. Websites and local support groups can help you recognize you aren’t alone and learn what helps others.
  • Practice specific therapy techniques. Counseling for depersonalization may involve practicing certain techniques to help resolve feelings of depersonalization on a daily basis. Two such techniques include cognitive behavioral therapy and dialectical behavioral therapy.
Mandy X

For further reading, take a look at these links: http://dopasolution.com/obsessive-compulsive-disorder/

https://careersinpsychology.org/what-depression-how-help/

Postpartum OCD and Psychosis: What is it, and How to Manage It

Postpartum OCD and Psychosis. https://katherinerosman.com/postpartum-ocd/

References:

http://apt.rcpsych.org/content/11/2/92.full

http://www.mayoclinic.org/diseases-conditions/depersonalization/basics/coping-support/con-20033401

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