Depersonalization: Overview

Transcription

1 DEPERSONALIZATION: CLINICAL FEATURES AND TREATMENT APPROACHES Fugen Neziroglu, Ph.D. & Katharine Donnelly, M.A. Bio-Behavioral Institute Great Neck, NY Depersonalization: Overview Symptoms: Depersonalization Feelings of detachment from: Emotions Sensations Autonomy of actions Sense of self Derealization Feelings of detachment from: The environment Size/shape of things The world feels dream-like

2 Development of Depersonalization Biological factors Neuroanatomical abnormalities Drug use: Marijuana, Hallucinogens, Ketamine Psychological factors and Trauma Acute trauma: Rape, exposure to combat, abusive relationships Enduring stress: Work-related stress over many years; neglectful or inappropriate parenting Diathesis stress Model Chronic vs. Episodic Depersonalization Depersonalization as a symptom or an experience is called secondary or episodic depersonalization. The sensations of depersonalization may come and go during the average person s life when faced with extreme discomfort of some kind. It is natural and adaptive, and allows people to numb themselves to overwhelming emotions during crisis. When these sensations fail to go away over weeks or years, an individual may be said to be suffering from Chronic Depersonalization or Depersonalization Disorder

3 Depersonalization Disorder DSM-IV-TR diagnostic criteria: 1.) persistent or recurrent feelings of being detached from one s mental processes or body, as if an observer 2.) Reality testing is intact 3.) Depersonalization causes significant distress and impairment in social, occupational, or other functioning 4.) Depersonalization is not the result of another disorder, substance abuse, or general medical condition What does DPD feel like? Individuals with DPD may describe their feelings and thoughts as foggy, fuzzy, numb, or dream-like. They often say that they feel as though they are out of their own bodies, disconnected from their actions or feelings, and unable to tap into experiences that they are intellectually aware of. People with DPD may feel that they are about to lose control or go crazy Many people with DPD obsess about the possibility that symptoms are evidence of some neurological condition (e.g. Alzheimer's, exposure to neurotoxins, or some other form of brain damage).

4 Impact of Depersonalization Avoidance of experiences that may elicit feelings of depersonalization Interpersonal dysfunction Avoidance of mentally-taxing activities Avoidance of socially demanding activities Obsessive thinking about psychological discomfort, origin of suffering, and ways to escape DPDrelated feelings. DPD, as it relates to Anxiety Depersonalization is sometimes considered an extension of extreme anxiety, much like panic Similar to panic, symptoms of depersonalization cause obsession about the origin of the discomfort, which then exacerbates the symptoms, and so on. Depersonalization may become more pronounced during times of stress, and tend to be evoked by other manifestations of anxiety (panic, OCD, PTSD, stress, hypochondriasis, etc.) Anxiety may cause depersonalization, and depersonalization may cause anxiety, creating an endless cycle of discomfort and obsessive thought about discomfort.

5 Pharmacological Options Naltrexone, an opioid antagonist, has been shown to reduce sensations of depersonalization in certain individuals. However, other medications typically treat the peripheral psychological complaints (e.g. depression and anxiety) associated with DPD SSRIs Tricyclic antidepressants Benzodiazepines Mood stabilizers (e.g. lamictal) Cognitive Behavior Therapy CBT has been found to be effective in reducing symptoms of depersonalization; behavioral activation & E/RP Behavioral activation relates to increasing involvement in reinforcing activities. Exposure exercises aimed at experiencing the discomfort of DPD or the discomfort that preceded its onset may be useful. Interoceptive cue exposure (exposure to extreme sensations, anxious arousal, etc.) Exposure to thoughts/imagery associated with traumatic events Exposure to sensations of DPD

6 Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 2003) ACT techniques overlap nicely with behavioral techniques. Essentially ACT implies acceptance of discomfort and commitment to pursue a life that is valued. This involves overriding impulses to act in ways that are counterproductive to your values, while being deliberate about your behaviors The aim is not to change or adjust your thoughts (we are not striving for rational thinking, but rather, functional behaving). Rather, ACT encourages accepting discomfort and unpleasant thoughts and not allowing them to control your behavior. Numbness! Numbness! What does this mean?! What are we going to do about this?! Find a way to Fix it! The Town Crier and Law Enforcement Okay! I m trying. I m doing everything that I know how to do!

7 Numbness! Numbness!... Hey!... What do we do?! ::poke:: WAKE UP! The Town Crier and Law Enforcement ZZZZZZZZZZZ When this system is unsuccessful or off guard. Ironic Processing (Wegner, 1992) tells us that unpleasant feelings become so relevant because you need to be alerted to them in order to get rid of them. This system continues to acknowledge discomfort, relentlessly Is Depersonalization in Part a Failure to Stay Present? Description of the Experience Depersonalization -Experiences seem to happen to you, rather than feeling as though you have autonomous control. -Emotional experiences and sensations are accurately labeled, but dulled. Lack of Present Moment Awareness -Your thoughts, the stories that you tell yourself, and basically everything that is going on upstairs is more relevant or more real than what happens external to the content of thoughts. -Unpleasant emotional experiences are either suppressed or turned into problem-solving exercises. Problem solving exercises result in rumination or emotional/thought suppression. Sometimes a solution to the problem results, but with regard to emotional problems over the average day, this is the exception rather than the rule. Both DP and lacking present moment awareness involve some kind of distance from the emotions that underlie emotional issues.

8 Depersonalization and Lack of Mindfulness (Cont.) Even after controlling for general psychological distress, a strong inverse relationship between mindfulness and DP symptoms was found (Matthias, et al., 2007). Obsession and rumination characterize both DP (Wolfradt & Engelmann, 2003) and lack of mindfulness (Shapiro et al., 2008). Anecdotally, one example is often used to illustrate both a failure of mindfulness and mild dissociation. We often drive from points A to B without memory of the process of getting there. This is a failure of present moment awareness and evidence of dissociation. Depersonalization & Mindfulness (cont.) Increased gray matter in the insula is associated with increased accuracy in interoception, a subjective sense of the inner body, and accuracy of identifying negative emotional experiences (Critchley, et al., 2004). Neuroimaging indicates that unusual somatosensory processing may be involved in DP (i.e. secondary processing: unification of the various sensory systems). Somatosensory cortices may not efficiently communicate. Mindfulness attempts to bring awareness of attention to sensory information, thereby making a deliberate process of something that is usually done automatically (and for people with DP, not very well).

9 Depersonalization & Mindfulness (cont.) Essentially, we are talking about metacognition ( I am aware that I am witnessing depersonalization. ) Unaware attention to discomfort: I can t believe how foreign my body feels right now. I can t believe that smoking weed led to this, I m never going to forgive myself for ruining my life. Aware attention: I am currently aware of this sensation of unreality; I feel the sensation in my feet that touch the ground, my thighs that touch the chair, etc. I am aware that my mind is saying that I have ruined my life. Experiential Avoidance : Individuals with DPD may avoid unpleasant thoughts/feelings/ sensations, in order to avoid feelings of DP. Dominance of Verbal Realities: An individual with DPD may become preoccupied by imagined scenarios of the future, and attention to the present moment is lost. Lacking Clarity of Values: This refers to lacking an awareness of what is truly important to you. Psychological Inflexibility Cognitive Fusion: Negative thinking about discomfort is a feature of chronic DPD; when you are fused with these thoughts, you believe that they reflect objective reality. Self-as-Content: Unpleasant thoughts and feelings may feel so inextricably linked to a DPD sufferer s sense of who she is. Narrow Behavioral Repertoire: A person with DPD may restrict what they are willing to experience in order to avoid intense feelings

10 ACT Case Conceptualization for DP Experiential Avoidance Reluctance to engage in exposure, avoidance of anxietyprovoking, socially-demanding, or cognitively-taxing activities Cognitive Fusion I am just looking for a road map to my mind. I need to find the entrance of this misery so that I can find the exit. I think that all of this suggests that some kind of neurodegenerative process is going on. Please explain DP again. Inaction, Avoidance Neglecting responsibilities, relationships, and flexibility in general Rumination, obsession (dominance of conceptualized past/future) I can t imagine what my life will be like if this does not go away. Acceptance/ Willingness: Allowing DP and other unpleasant feelings to be there without trying to force them away or change them. Present Moment Awareness: Observing what is happening right now, rather than attending to thoughts unrelated to what is directly in front of you Clarity of Values: Having a strong sense of what is important and meaningful to you in life Psychological Flexibility Cognitive Defusion: Viewing thoughts and feelings as what they are (mere mental events), not what they appear to be (reflections of reality). Transcendent Sense of Self: the self is constantly changing and is not defined by any one trait, feeling, role, or thought pattern, including DP Committed Action: Acting according to what is meaningful in your life, despite any discomfort that might accompany these actions.

11 ACT Treatment Suggestions Establishing the idea that solving the problem of depersonalization may have led to more suffering than relief. Fostering willingness to experience discomfort Cognitive Defusion: changing the context of nagging reflections on DP; experiencing these thoughts as just thoughts; undermining the importance that is placed on evaluations, rumination about the future/past, etc. Values Clarification/Committed Action: Creating an agenda to pursue areas of life that are important, rather than being governed by perceptual discomfort. Mindfulness Increased contact with present moment internal experiences Increased contact with present environmental observations