Depersonalization and Derealization: Case Presentation

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Depersonalization and Derealization Case
Presentation

• Jaclyn Newman, PGY III

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Mr.Smith

• He is 50 year old male who has been in therapy
  for 8 years after an inpatient hospitalization
  during an impending divorce. He had symptoms of
  depression and suicidality during the inpatient
  stay, but also noted a very disturbing sense of
  not knowing or recognizing his wife during that
  time. He says he had a hard time remembering or
  feeling connected to the fact that he had ever
  been married. He found this very unsettling and
  began therapy after discharge.

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Mr. Smith

• When Mr. Smith begins therapy, he describes some
  symptoms that began troubling him during college.
  Now that he has been in supportive and
  psychodynamic psychotherapy, he has become very
  educated about his pscyhiatric history, family
  dynamics, current diagnosis. He journals
  frequently throughout the day. He has read
  several books about his dx. He says he is
  diagnosed with MDD, Depersonalization,
  Derealiztion, and Borderline Personality DO.

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Mr. Smith

• Mr. Smith has very diligent about therapy always
  makes appointments, journals, medicine
  compliance.
• He develops concerns over the 8 years of therapy
  about DID DO due to what he describes as
  experiencing ego states.
• He wants to pursue DID therapy, even though he
  has reservations about changing therapists after
  so many years. The therapeutic alliance has been
  very positive experience, but his therapist
  refers him to explore DID diagnosis.

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Mr. Smith

• Upon our first meeting, he presents a
  well-organized, typed sheet of symptoms that he
  says began in college page 1 about DP/DR.
• He also presents a typed sheet describing each
  ego state he has experienced railroad smith,
  little boy smith, gay smith, young professional
  smith, ect.
• He is knowledgeable about his current dx, well
  read, compliant. He is highly educated, currently
  close to finishing his phD dissertation in his
  field and has recently published a book in his
  field.
• 2 inpatient hospitalizations, no actual suicide
  attempts. He continues to have passive thoughts
  about death. Denies AH,VH. No substance abuse.
• He describes his mother has BPDO verbally
  abusive, critical, emotionally abusive. No hx of
  sexual abuse.
• He has been married for 22 years, but had little
  to no sexual contact before he was married at age
  36. 2 Stepchildren. His wife has serious gambling
  troubles.
• Current meds Effexor 300mg QD and Buspar 40mg QD

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Depersonalization

• numbing-dont seem able to feel any emotion
• Disorientation-sometimes I get confused as to
  what season it is-fall or spring-I dont know
  what season it is. Maybe is takes a minute to
  figure it out
• Parts of my body-at times parts of my body dont
  seem to be real or to belong to me, particularly
  my hand and arm.
• Automaton-I hear my voice saying things the way
  I usually say them, but I am detached, a couple
  of feet behind myself, observing
• I often find myself in the position of the
  observer, observing myself.
• I ruminate a lot, it seems like all the time. I
  ruminate about who I am, where we come from,
  where we are going, death, non-existence I often
  despair and panic about these things as if it is
  absolutely necessary that I know answers to these
  questions.
• Fear of forgetting who I am. The patient says
  he sees his therapist and keeps so many journals
  because he has a fear that he will suddenly
  forget who he is. He says he can read the
  journals or see his therapist to remind him of
  who he is if this ever happens. He references the
  inpatient hospitalization and who he forgot he
  had ever been married.

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Depersonalization

• DSM IV classifies depersonalization among
  dissociative dx
• A. Persistent or recurrent experiences of feeling
  detached from, and as if one is an outside
  observer of, ones mental processes or body (e.g.
  feeling like one is in a dream).
• B. During the depersonalization experience,
  reality testing remains intact.
• C. The depersonalization experience does not
  occur exclusively during the course of another
  mental disorder, such as Schizophrenia, Panic
  Disorder, Acute Stress Disorder, or another
  Dissociative Disorder, and is not due to the
  direct physiological effects of a substance (e.g.
  a drug of abuse, a medication) or a general
  medical condition (e.g. temporal lobe epilepsy).
• Criteria state patient may have either or both DP
  and Derealiztion.
• Lifetime prevalence is 1 however DP and DR can
  be common in childhood and adolescence. Studies
  state that 66 of adults experience DP/DR during
  traumatic event, such as a car accident. Nearly
  80 in-patient psychiatric patients experience
  DP/DR during the hospitalization. Most patients
  who develop DP/DR diagnosis have first onset
  during a traumatic event in adulthood.
• The patient does not have amnesia during or after
  episodes. There is no delusional component.

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That neuro stuff

• Neurological conditions that may be associated
  with depersonalization epilepsy, migraine, mild
  TBI.
• Depersonalization can be presenting symptom of
  Alzheimers, MS, Neuroborreliosis (Lyme disease),
  ALS. May want to consider MRI if sudden, new
  onset.
• Lesions have been localized in parietal lobes
• PET scans show patient with DP have abnormal
  uptake in parietal, temporal, occipital lobes.

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Two Neural Networks Implicated

• Relevant to the experience of emotional feelings
  amygdala, anterior insula, limbic structures
  (particularly anterior cingulate and
  hypothalamus) structure. This emotional networks
  are regulated by the prefrontal cortex. It is
  suggested that prefrontal cortex suppression or
  inhibition may produce emotional numbing.
• The experience of embodiment, feelings of
  agency (that one is seamlessly unaware of being
  in ones body), body ownership is governed by
  parietal and fronto-limbic tracts. Patients with
  lesions in these areas experience
  disembodiment.

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The anxiety piece

• Research has shown a cyclic pattern between
  anxiety and DP. Patients often experience both DP
  and anxiety. The strangeness of feeling of
  isolation caused by DP fuels anxiety.
  Depersonalization mechanism is then strengthened
  as a defense against the anxiety.
• This is described as the anxiety process at odds
  with the manifestations of anxiety.
• Patients with DP/DR have high serum cortisol as
  well as urine/serum metanephrines suggesting
  higher levels of anxiety however, they have
  frontal-limbic disconnect from anxiety resulting
  sluggish autonomics as demonstrated by blunted
  skin conductance recordings.

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Co-morbidities and common features

• Depression and anxiety are common psychiatric
  co-morbidities
• OCD is not a common feature in recent study,
  less then 6 of patients with OCD have DP/DR.
• DP/DR can be associated with BPDO
• Patient usually seek help for DP/DR after
  approximately 12 years of on-going symptoms,
  onset typically young adult after traumatic
  event.
• Symptoms begin as episodic, then periods between
  episodes and length of episodes progress.
• Patients typically have obsess ional self
  monitoring and self observation. They journal
  diligently and often ponder If Im not really
  me, then who am I?
• DP/DR has no relation to delusional DO or
  psychosis. Patients have no positive altered
  sensorium hallucinations, paranoia, delusions.
  Antipsychotics worsen symptoms of DP/DR. Note
  symptoms of DP/DR are very difficult to describe.
  Most patients will use metaphors and as if
  language to describe Its as if Im outside my
  body, ect. The as if concepts and metaphorical
  speaking should be clue that delusional DO and
  psychosis is not likely the dx as many psychotic
  patients fail to use/grasp allegorical or
  metaphorical concepts.
• Dissociation. DP/DR is listed with Dissociative
  Dos however, one stand out feature of DP/DR is
  that the patient is very aware of symptoms and
  change in perception of environment/self.
  Dissociation DO involve lack of awareness of
  change in perceptions and are associated with
  amnestic quality of symptoms and episodes. DP/DR
  is thus very different from dissociation.
• Affect may range from completely normal, which is
  most common. There could be some blunting

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UK Birth Cohort Study

• All single births to married women in March of
  1946 among different backgrounds (N5362).
• The goal is to observe and gather data about
  these individuals throughout their lifetime,
  gather biopsychosocial data and observe outcomes.
  
• These individuals began having psychiatric
  interviews at age 32, but had been unknowingly
  observed and evaluated throughout their lives
  with respect to physical, mental health. They
  have routine psychiatric evals throughout the
  remainder of their adult lives.
• This is the study that give values of prevalence
  of DP/DR at .8-1.2 in population.
• The study found no association with
  socio-economic status, parental death or divorce,
  self reported accidents, childhood depression,
  tendency to daydream, or reactions to criticism.
  There was equal gender split.
• They did find only one single significant
  predictor of adult DP teacher rated anxiety at
  age 13. There was also significant predictive
  value in reported emotional abuse in childhood
  (defined as parental criticisms, insults,
  shouting, blaming, and scapegoating). There was
  also associations with personality disorders in
  long range outcomes of these individuals.

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Back to Mr. Smith

• Mr. Smith reports that his mother was very
  critical, verbally abusive, emotionally abusive.
• He reports that he has always had a difficult
  time getting close to people. He had his first
  intense intimate relationship in college. This
  was first (superficial) sexual experience. He
  says one night, he sat up in middle of night and
  felt something wasnt right. The symptoms of
  DP/DR had sudden onset that night and have
  increased in frequency/duration over the years.
• He began to have some identity issues. He says he
  also began to experience what he refers to as the
  emergence of gay smith. He struggled with this
  for several years.
• He developed depression, DP/DR so severe, he was
  hospitalized in college and dx MDD with
  psychotic features.
• He went on to finish college, married at age 36,
  second hospitalization during time when divorce
  seemed imminent. He was diagnosed with MDD,
  DP/DR, BPDO at that time.
• He has continued to struggle with identity
  issues, journals daily. Number one fear is
  forgetting who I am.

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Derealiztion

• DR is an alteration in the perception or
  experience of the external world so that it seems
  strange or unreal.
• In literature, it is described as patient losing
  emotional colouring. This is the process of the
  brain adding memory and experience to produce
  emotional response to what we observe around us.
• Patients describe this as loss of emotional
  response to visual landscapes. Photos of self and
  friends/family produce no emotional response,
  even though the patient recognizes the people in
  the photo.
• Again, affect may be blunted, but if often normal

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Patients describe Derealiztion

• colors are dull
• the world and landscapes are not interesting
• people seem odd as if they are actors on a
  stage speaking in a robotic way
• it is as if there is a fog, film, or glass
  between me and the world.
• as I hear music, there is no response in me
• I know he is my husband next to me by his
  appearance, he might be anybody for all I feel
  towards him
• things look flat, like 2D

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Neurology of Derealiztion

• This is also referred to as visual
  hypoemotionality in neurological models that
  explain this process.
• The process has been traced by study of lesions
  to right or bilateral occipitotemporal lesions
  that disconnect temporal-limbic areas.
• Studies have shown a lack of activity in the
  anterior cingulate cortex when DP/DR patients are
  exposed to visual images that should provoke
  response such as graphic, gory images. This
  relates to inhibition of fronto-limbic tracts.

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Note about Derealization

• DP and DR are listed as criteria A. Patient may
  have DP or DR to meet criteria.
• Research has conclusively shown that DR does not
  occur independently of depersonalization
  although one may have depersonalization without
  derealization.
• If patient presents with complaint of depression,
  panic attacks and palpitations, tremors,
  derealization without depersonalization, the
  diagnosis is..

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Labyrinthitis

• Labyrinthitis until proven otherwise.
• Labyrinthitis is an inflammation of the inner
  ear. Patients can experience vertigo,
  derealization, panic attacks, depression,
  tinnitus, vestibular symptoms.
• There are interesting theories linking these
  symptoms
• 1. Psychosomatic model vestibular dysfunction
  occurs as a result of anxiety
• 2. Somatopsychic model panic disorder triggers
  misinterpreted internal stimuli that are
  interpreted as signifying imminent physical
  danger. Heightened sensitivity to vestibular
  sensations leads to increased anxiety and, though
  conditioning, drives the development of panic
  disorder
• 3. Network alarm theory panic which involves
  noradrenergic, serotonergic, and other connected
  neuronal systems.panic can be triggered by
  stimuli that set off false alarm via afferents
  to the locus ceruleus, which then triggers
  neuronal network. The network mediates anxiety
  through limbic, midbrain, prefrontal tracks.
  Vestibular dysfunction in the setting of
  increased locus ceruleus sensitivity may be a
  potential trigger.
• What is first line tx? SSRI. SSRIs have shown
  neuronal repair and growth in the labyrinth and
  should be considered first line tx for suspected
  labyrinthitis. Although steroids, antibiotics,
  antivirals may be considered for underlying
  causes, often the underlying cause could be
  trauma or may remain undetermined, SSRIs are
  shown to affect long term outcomes.

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Derealiztion

• Excessive Caffeine intake can induce
  derealization. If patient presents with exclusive
  complaint of derealization, tremor, palpitations,
  review caffeine intake.
• Studies have shown large doses of benzos can
  resolve caffeine induced Derealization.

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Mr. Smith

• Mr. Smith describes derealization symptoms as
• Glass barrier-as if there is a pane of glass
  between me and the outside world. Or, as if I am
  in glass bubble.
• The mirror-when I look into a large mirror it is
  as if I see the real me and the real world, and I
  am inside the mirror looking out.
• Familiar places look strange-as if I am on an
  alien planet or as if I am in the 1940s. Colors
  look intense or like heaven.
• Numbing-I often feel like there is a filth,
  dark/grey hazy dullness, veil-like fog

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Approaching Treatment for DP/DR

• Getting started start with the Cambridge
  Depersonalization Scale. This is a tool that is
  widely used and respected in research for
  following pharmacological tx and tracking
  symptoms as way to gage effectiveness of
  treatment. It is free on-line.
• There are 29 symptoms of DP/DR on scale and
  patient is asked to give ratings of frequency and
  duration of each symptom.
• Re-test your patient at 12 weeks intervals after
  changing medication regimen.

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Treatment

• Psychotherapy has not yielded significant
  improvement in DP/DR symptoms in cohort studies
• SSRIs have shown no significant improvement,
  there are no studies demonstrating effectiveness
  of SSRI on DP/DR symptoms however, patients with
  DP/DR frequently have depression and anxiety.
  Citalopram or Effexor are popular choices for
  management of depression, anxiety in DP/DR
  patients.
• Benzos. There are some Klonopin studies that do
  not show impressive results for symptoms patient
  reported mixed results for benzodiazepines.
• Antipsychotics have been shown to worsen DP/DR
  symptoms and should be avoided.
• A interesting double blind study published in
  February 2012 showed patients have 50 reduction
  in Cambridge DP scores after 12 weeks on Lamictal
  300mg PO QDay. Lamictal seems to the emerging
  treatment of choice for the symptoms of DP/DR.

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Mr.Smith

• Mr. Smith is in process of taking Cambridge DP
  Scale and is considering Lamictal trial to add to
  regimen of Buspar and Effexor.

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What about Ego States?

• Mr. Smith states that he experiences the
  emergence of several ego states. He has never
  had an amnestic episode in which another
  personality emerges and takes over. He
  describes being aware that he changes dress,
  mannerisms, mind-sets, beliefs, behaviors when
  feeling presence of ego states gay smith,
  little boy smith, dad, slasher, young
  professional smith, railroad smith, ect.
• He does not display classic Dissociative Identity
  Disorder there is not dissociation and amnestic
  episodes. He finds these ego states very
  unsettling and disturbing. Like the DP/DR
  symptoms, he is acutely aware of the
  symptoms/influence/presence of these ego states
  and wants treatment.
• There is not literature linking DP/DR to this ego
  state experience.
• Perhaps ego states are product of personality
  disorder features?
• Could the ego states be a product of obsessive
  self analysis, identity crisis common in DP/DR
  patients?

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Considerations

• Thank you and enjoy the weekend!
• Dr. Kelley precepts this case.
• References available upon request.