Depersonalisation-Mod 3 Flashcards
What is depersonalisation?
‘alteration in the perception or experience of the self so that one feels detached from and as if one is an outside observer of one’s mental processes or body’ (DSM-IV).
-Disturbing sense of being ‘separate from oneself’, observing oneself as if from outside, feeling like a robot or automaton
-Strange and disturbing sense of unreality in one’s experience of oneself (DP) and one’s surroundings (DR).
What is the epidemiology of depersonalisation disorder?
-Epidemiological reviews (Bebbington et al, 1997; Hunter et al, 2004): conclude that clinically significant depersonalization may affect 1–2% of the general population, with a gender ratio of about 1:1.
What is derealisation?
Derealization Threatening sense of unfamiliarity or unreality in the environment, perceptual anomalies may be present, other people may feel like actors in a play
What is de-somatisation?
De-somatization: diminution, loss or alteration of bodily sensations, sense of disembodiment; there may be a raised pain threshold
What is de-affectualisation?
De-affectualisation: diminution or loss of emotional reactivity: emotions seem to lack spontaneity and subjective validity; this may affect intimate relationships
What is de-ideation?
Difficulty in concentrating, “cotton wool in head”.
What does the clinical assessment include for DPD?
Take a history;
-Nature of episodes: episodic/intermittent
-Any associated symptoms (e.g. migraine)
-Symptom scales e.g. CDS, DES
Consider differential :TLE, Anxiety/depression, psychosis – DPD has the “as if” quality.
What investigations can be done for DPD?
Investigations
-CT/MRI, EEG if suspicion of epilepsy or-other organic process
-Routine bloods incl. thyroid function
-Other investigations if history suggestive of organic pathology
What is the Cambridge Depersonalisation Scale (CDS)?
-29-item scale
-Self-rated
-Asks about experiences over last 6 months
-Scores for frequency and duration, maximum score 10 per item
-Example statements:
‘My favourite activities are no longer enjoyable’,
‘What I see looks ‘flat’ or ‘lifeless’, as if I were looking at picture.
What is the relationship between anxiety and DPD?
-Often history of anxiety and/or panic attacks
-Many patients have current co-morbid anxiety
-DP/DR seem to be normal response to threat
e.g. Mayer-Gross 1935 “Pre-formed response”
-Noyes and Kletti 1977- DP/DR in response to life-threatening danger
“Vicious circle” between anxiety and DP/DR: fuel each other
What are some pharmacological management options for DPD?
Pharmacological
-Lamotrigine +/- SSRI
-Clonazepam
-Naltrexone
-Clomipramine
-Psychostimulants (Methylphenidate, Modafinil)
What are the effects of lamotrigine?
-Lamotrigine reduces excitatory amino acid neurotransmission, predominantly glutamate, by blocking Na-dependent channels and stabilising the neuronal membrane.
-It has been found to block depersonalisation and derealization induced by the NMDA receptor antagonist ketamine (Anand et al 2000).
Is lamotrigine useful for DPD?
-In clinical settings, lamotrigine has been effective in reducing symptoms of DPD, particularly when given in combination with an SSRI (Sierra, Baker, Medford et al, 2006, Clinical Neuropharmacology 29: 253-258).
What are some non-pharmacological management options for DPD?
Non-pharmacological
-CBT approach
-Attentional training
-Mindfulness techniques?
-rTMS – some evidence for improvement with rTMS applied to right VLPFC
Describe the process of CBT: diary keeping
Diary keeping
-If chronic, then hourly (if possible)
What are you doing in that hour period with 0-10 rating of DPRD severity
-If infrequent, then when occurs,
recording the situation, severity
rating, duration, mood, thoughts,
behaviour
How does diary analysis (for CBT) work?
-Analyse diary for fluctuations
-What is the range of scores?
-What are the highest scores and the lowest scores?
-Highlight each of these in different colours
-Create a list of times with the -DPRD is worse vs better
-What might the underlying mechanisms be for each of these?
-Can schedule activities in line with this information
-Often highlights the role of anxiety / low mood in worsening DP
What are ‘grounding strategies’?
Aims to refocus a person’s attention to the present using:
Surroundings
Words / statements
Image
Posture
Objects
Senses: sight, sound, touch, taste, smell
Key is to use these strategies asap during initial warning signs of DPRD
What is ‘thinking process’ focused CBT?
Strategies to reduce rumination & worry
Understanding and manipulating symptom focused attention (spotlight metaphor)
What is ‘behaviour’ focused CBT?
-Pros and cons of checking behaviours
-Internet searching/ Dr shopping
-Avoiding avoidance
-Getting back to doing the things you’ve stopped doing because of the DPRD in a graded way, one step at a time
What was found in fMRI studies in relation to emotional experience in DPD?
-Simple emotional paradigm:
-Viewing aversive and neutral images in the scanner
International Affective Picture System (IAPS)
Neural response
-Normal controls showed anterior insula activation to aversive scenes
-This area has been implicated in the normal response to aversive stimuli.
-DPD patients did not show anterior insula activation to aversive scenes
-Consistent with self-reported lack of emotional reactivity
-Area of R ventral PFC (BA47) possibly associated with suppression of emotional response
What is the role of the insula in the integration of bodily feedback in awareness?
-Insula involved in normal response to aversive stimuli
Disgust (Phillips et al 1997 and other emotions
-Appears to have specific role in integrating bodily sensations and sensory feedback into emotional feeling states
What is the relevance of DPD to other conditions?
-In DPD, the depersonalization symptoms are intense, chronic and occur largely in the absence of other symptoms
-However milder or less frequent depersonalization symptoms are common in other conditions
-Emotionally unstable personality disorder
-PTSD
-Schizophrenia
What is emotionally unstable personality disorder?
-ICD F60.31: “There are usually chronic feelings of emptiness”.
-Phenomenology of “feelings of emptiness”?
-Relationship to depersonalisation?
-Associated with emotional turmoil
