Depersonalization and Derealization: Case Presentation

1. Depersonalization and Derealization: Case Presentation Jaclyn Newman, PGY III

2. 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.

3. 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.

4. 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.

5. 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

6. Depersonalization • “numbing-don’t seem able to feel any emotion” • “Disorientation-sometimes I get confused as to what season it is-fall or spring-I don’t know what season it is. Maybe is takes a minute to figure it out” • “Parts of my body-at times parts of my body don’t 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.

7. 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, one’s 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.

8. That neuro stuff • Neurological conditions that may be associated with depersonalization: epilepsy, migraine, mild TBI. • Depersonalization can be presenting symptom of: Alzheimer’s, 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.

9. 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 one’s body), body ownership is governed by parietal and fronto-limbic tracts. Patients with lesions in these areas experience “disembodiment”.

10. 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.

11. 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 I’m 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: “It’s as if I’m 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

12. UK Birth Cohort Study • All single births to married women in March of 1946 among different backgrounds (N=5362). • 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.

13. 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 wasn’t 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”.

14. 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

15. 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”

16. 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.

17. 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……..

18. 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.

19. 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.

20. 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”

21. 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.

22. 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.

23. 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.

24. 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?

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