DEPERSONALIZATION: CLINICAL FEATURES AND TREATMENT APPROACHES

Fugen Neziroglu, Ph.D. & Katharine Donnelly, M.A. Bio-Behavioral Institute Great Neck, NY 11021

What is Depersonalization?

Depersonalization is conceptualized as a psychological numbing reaction that is evoked during times of extreme stress, representing an adaptive mechanism when experienced during discrete episodes.

Depersonalization is an experience that does not necessarily mean you have a psychological disorder.

50-70% of people would say that they have experienced depersonalization at some point in their lives.

Depersonalization Disorder (DPD) is estimated to occur in about 2% of the population (Sierra, 2008).

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Depersonalization Disorder (DPD) Persistent or recurrent experiences of feeling detached

from one’s mental processes or body, as if an observer Depersonalization causes significant distress or

impairment in social, occupational, or other functioning

During the experience of depersonalization, reality testing remains intact, one is aware of his/her experiences are unusual

The depersonalization experience does not occur during the course of another mental disorder and is not due to the physiological effects of a substance or a general medication

(American Psychiatric Association, 2000)

Coining the DPD

In 1898, Ludovic Dugar, a French psychologist, coined the term depersonalization to describe the lack of normal mental function, or personalization, in those experiencing troubling symptoms.

Two types of DPD

ChronicEpisodic

Main Feelings of DPD “Auto-pilot”- one may feel as if an unknown force

has taken control of their body and that their body acts independently of their brain.

Mental and Emotional Numbing -Individuals with DPD report that they use a limited percentage of their brain during daily activities or that they do not feel any true emotional connection in their relationships, even to their spouse or children.

“Gone Blank” - Individuals with DPD may have difficulty concentrating, their thoughts may be jumbled or confused, or they may have difficulty retaining new information.

Depersonalization vs. Derealization

Depersonalization refers to an altered perception of oneself.

Derealization refers to alteration of the environment as it is perceived.

Derealization is described as the experience of the external world as strange or unreal. (e.g.one’s vision may be distorted so that objects appear larger or smaller than they really are, a familiar scene may seem foreign or somehow perverted, or objects in the environment may seem like they are somehow not the same as they are known to be, as though they are not the right size/shape, or alien in some other way).

Derealization as Part of DPD

Derealization is often a manifestation of DPD. Derealization may cause one to question the purpose of things

in their everyday environment. (e.g. The people with whom you interact on a regular basis may seem unfamiliar to you or mechanical).

The world may appear unreal or artificial (e.g.one might experience unusual physical and perceptual sensations and have sensations of weightlessness or loss of basic senses such as, smell, touch, taste).

One may experience feelings of being slowed down or sped up.

The experience of everything one is able to observe, including internal sensations may be distorted.

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).

Symptoms of DPD

Do you feel hollow inside? Do you feel like you lost your sense of

self? Do you feel like you are observing

yourself from the outside, looking inside? Do you feel like a robot? Are you numb, unable to feel emotions,

although you know what you are supposed to feel?

Symptoms of DPD

Would you describe your experience like the life of the “living dead?”

Does the world around you seem strange, like you do not perceive it as others do?

Do your body and mind seem disconnected? Does everything around you seem foggy,

unreal? Are you living in a dream world, everything

surreal? Are you an actor on stage but not feeling your

part?

Symptoms of DPD

Do you spend a lot of time thinking about philosophical or religious issues (e.g. why do we exist, do we exist, who is really talking, what is time and space?).

Does your thinking seem separate from your body?

Symptoms of DPD

Are you paying a lot of attention to your bodily sensations and/or to your thoughts?

Do you fear that you are not controlling your own actions?

Are you overly aware of noise? Do objects look different than before?

Symptoms of DPD

Do you feel there is an inner voice that is yours, but at the same time converses and interrupts your other thoughts?

Do you feel detached from things and people around you?

Do you feel like you are in a constant state of detachment?

Behaviors, Feelings, and Thoughts Associated with DPD Sensory ChangesPerceptual ChangesMood ChangesChanges in the Way One Thinks

Behavioral Changes

Sensory Changes

Feeling UnrealFeeling as if one is living in a dream world

Decreased sensations (things may not taste or smell the way they used to)

Perceptual Changes

Objects appear to be further or nearer

Colors may appear more vivid (e.g. the world seems brighter)

One’s voice may appear as if it were altered

Mood Changes

Feeling anxiousFeeling depressedFeeling numbFeeling emotionally detached

Changes in the Way One Thinks Thoughts appear foreign (e.g. one’s

thoughts seem to belong to someone else other than the self)

Confusion Self-focus (attempts to figure out what

has happened to one’s brain and way of thinking)

Rumination

Behavioral Changes

DisorganizationDifficulty completing a taskDetachment and distancing oneself from others or during interactions with others

Triggers of DPD

Trauma Marijuana Extreme family dysfunctionality Extreme and prolonged stress Extreme and uncontrollable emotions

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 DPD-related 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.

The Development of DPD

Human behavior is influenced by a variety of variables including environmental, biological, and cultural aspects.

Trauma

Trauma can be complex and cumulative (e.g. child abuse) or it may be one big incident (e.g. experiencing the events of 9/11)

Trauma does not have to be experienced directly to develop DPD. Bystanders can develop similar reactions to victims (e.g., if a child of rape is born and is made aware of her beginnings, this legacy might cause significant emotional trauma for her while growing up, and contribute negatively to her development).

Trauma Common traumas that results in DPD include,

physical, sexual, and/or emotional abuse, neglect, rape, and victimization among others.

Disruption of cultural identity could also become a source of trauma. Emigration to a completely different culture or exposure to sociohistorical events (e.g. tyranny or terrorism) may cause intense feelings of fear or shame, resulting in trauma .

Context is a crucial factor to consider (Seligman & Kirmayer, 2008). If your social environment, peers, and/or family considers something significant, then you are likely to consider it significant as well.

Cultural Factors In the Balinese culture, self-preservation is highly valued,

and emotional pain is swept aside to constantly present a façade of smoothness and strength to others (Wikan, 1990).

Members of other cultures avoid strong emotions because they are thought to be correlated with bad health (Wellenkamp, 2002).

In some parts of Turkey, it is not acceptable to express emotions such as depression or anxiety, and therefore people may develop hypochondriacal symptoms and/or dissociate in order to not experience unacceptable negative emotions.

In cultures where emotional expression is discouraged, dissociation may be a preferable alternative if you are struggling with intense unpleasant emotions.

Substance Abuse

Marijuana may trigger panic attacks, dissociative states, a combination of the two.

Individuals have reported that marijuana use makes them more introverted, more aware of perceptual changes, objects may seem at a distance, the ability to respond to questions may be slowed down, it is difficult to think clearly, and the body seems estranged. These symptoms echo depersonalization

While marijuana is the most common trigger of depersonalization, any drug could serve as a trigger.

Other hallucinogens that may cause this reaction include PCP, or ketamine.

Neurobiology Sierra and Berrios (2001) compared historical reports of dissociation

disorder with those of current patients. Their results showed consistency of clinical manifestations over time. Despite the vast changes that occur in culture and society throughout history, symptoms of DPD are relatively constant. There may be some unchanging, innate biology involved in the disorder.

Some researchers have suggested that dissociation occurs to inhibit emotional responses when the person does not have control over the situation (Baker et al., 2003).

When people with DPD undergo FMRI and look at distressing or disgusting images, their sympathetic responses are reduced (Phillips et al., 2001). DPD patients also rated unpleasant pictures as less arousing (Sierra et al., 2002b) and were less sensitive to detection of angry facial expressions. Anger communicates a great threat and usually induces anxiety; therefore, DPD patients may have an inhibited response to pictures of such a provocative emotion (Montagne et al., 2007).

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

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.

The Town Crier and Law Enforcement“Numbness!

Numbness! What does this mean?! … What are we going to

do about this?! Find a way to Fix

it!”

“Okay! I’m trying. I’m

doing everything that I know how to do!”

The Town Crier and Law Enforcement

“Numbness! Numbness!...

....Hey!.... What do we do?!”

::poke::

“WAKE UP!”

“ZZZZZZZZZZZ”

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.

When this system is

unsuccessful or off

guard….

This system continues to acknowledge discomfort, relentlessly

Is Depersonalization in Part a Failure to Stay Present?

Depersonalization

Lack of Present Moment Awareness

Description of the Experience

-Experiences seem to happen to you, rather than feeling as though you have autonomous control.

-Emotional experiences and sensations are accurately labeled, but dulled.

-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.

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).

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.”

Narrow Behavioral

Repertoire: A person with DPD may restrict what they are willing to

experience in order to avoid intense

feelings

Narrow Behavioral

Repertoire: A person with DPD may restrict what they are willing to

experience in order to avoid intense

feelings

Experiential Avoidance :

Individuals with DPD may avoid unpleasant

thoughts/feelings/ sensations, in order to avoid feelings of

DP.

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.

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.

Self-as-Content:

Unpleasant thoughts and feelings may

feel so inextricably linked to a DPD

sufferer’s sense of who she is.

Self-as-Content:

Unpleasant thoughts and feelings may

feel so inextricably linked to a DPD

sufferer’s sense of who she is.

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.

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.

Psychological

Inflexibility

Psychological

Inflexibility

Lacking Clarity of Values: This refers to lacking an awareness of what is truly important to

you.

Lacking Clarity of Values: This refers to lacking an awareness of what is truly important to

you.

ACT Case Conceptualization for DP Experiential Avoidance

Reluctance to engage in exposure, avoidance of anxiety-provoking, 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.”

Committed Action: Acting

according to what is meaningful in your life, despite any discomfort

that might accompany these

actions.

Committed Action: Acting

according to what is meaningful in your life, despite any discomfort

that might accompany these

actions.

Acceptance/Willingness:

Allowing DP and other unpleasant

feelings to be there without trying to force them away or change them.

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

Present Moment

Awareness: Observing what is happening right now, rather than

attending to thoughts

unrelated to what is directly in front

of you

Transcendent Sense of Self:

“the self” is constantly

changing and is not defined by any one trait,

feeling, role, or thought pattern,

including DP

Transcendent Sense of Self:

“the self” is constantly

changing and is not defined by any one trait,

feeling, role, or thought pattern,

including DP

Cognitive Defusion:

Viewing thoughts and feelings as what

they are (mere mental events), not what they appear to

be (reflections of reality).

Cognitive Defusion:

Viewing thoughts and feelings as what

they are (mere mental events), not what they appear to

be (reflections of reality).

Psychological

Flexibility

Psychological

Flexibility

Clarity of Values: Having a

strong sense of what is important and meaningful to

you in life

Clarity of Values: Having a

strong sense of what is important and meaningful to

you in life

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

Case of “Michelle”

History of anxiety and depression Precipitating factors

Unsupportive parental involvement Parents fought constantly Emotional expression was ignored or

suppressed Incidence of marijuana use initiated

dissociative state

Case of “Michelle” cont.

Description of her experience Does not trust emotional experiences Focused on internal experiences (examining,

trying to determine the source of, labeling and judging)

Unable to establish and/or maintain feelings for significant others

She becomes despondent about her experiences, and attributes depressed feelings to depersonalization.

Case of “Michelle” cont.

Behaviors associated with DPD Avoiding social situations/sabotaging

romantic relationships Visiting doctors

Extensive blood work/brain scans Visiting specialists: neurologists, endocrinologists,

internists, nutritionists, ayurvedic doctors, etc. Researching alternative treatments:

Blue light filter Supplements Tanning

Case of “Michelle” cont. ACT Treatment Plan:

Dismantle the authority of experiential discomfort (i.e. anxious thoughts about DPD will convince you that you have no choice but to act in accordance with them; this allows DPD to dominate you).

Establish Creative Hopelessness (recognize that you have tried everything that a person could try to feel better, and it hasn’t worked; maybe chasing pleasant feelings and trying to exile discomfort is not working).

Foster willingness to experience discomfort and acceptance of all experiences

Practice mindfulness (present moment orientation, rather than being pulled off on tangential rumination about discomfort)

Act according to values, rather than emotions: clarify what is truly meaningful to you, and pay attention to how anxious action can pull you off of this course.

Behavioral practice of the life you want to live, even if your emotions don’t always reflect this life.