Depersonalization/Derealization Disorder 1

Depersonalization/Derealization Disorder

Holly Gerard

University of Maine at Augusta

December 2016
Depersonalization/Derealization Disorder 2

Introduction

Depersonalization/derealization disorder (DDD) involves significant ongoing or recurring

experience of one or both dissociative conditions in the absence of substance use, or medical or

other psychiatric condition. Depersonalization is a condition in which an individual feels a sense

of unreality or detachment from ones mind, self, or body. These individuals may feel that they

are outside their bodies watching their lives occur. Derealization is a condition in which an

individual experiences detachment from ones surroundings. (Halgin & Whitborne, 2010, p. 217)

DSM II, III, and IV listed derealization as an associated feature of depersonalization

disorder. DSM-V has included derealization in the name of the disorder since they often

accompany each other. This move brings the American classification closer to the International

Classification of Diseases categorization of feeling unreal as depersonalization-derealization

syndrome (Bezzubova, 2014). Although, ICD-10 categorizes depersonalization-derealization

syndrome as a neurotic disorder and DSM-V still groups depersonalization/derealization disorder

with dissociative disorders.

Despite the individual experience of feeling unreality in mind or body, they are still

aware of reality and understand that their experience is unusual. The individual may appear

apathetic while experiencing significant levels of distress. Symptoms can show in early

childhood; the average age of development is 16. Statistics show that less than 20 percent of

individuals with depersonalization/derealization disorder first experience symptoms after age 20.

(Wang, APA, 2016)

Depersonalization has been shown in research to occur fleetingly in 50-70% of the

population, especially at the time of a traumatic event. DDD has a prevalence of approximately
Depersonalization/Derealization Disorder 3

two percent and is associated with significant morbidity, but often goes undetected or

misdiagnosed, leading to delays in treatment. (Hunter et al., 2004)

Assessment instruments used in the detection and measurement of

depersonalization/derealization disorder are the Structured Clinical Interview for Dissociative

Disorders (SCID-D), Dissociative Disorders Interview Schedule (DDIS), Dissociative

Experiences Scale (DES), and Cambridge Depersonalization Scale (CDS). The SCID-D and the

DDIS are both structured interviews performed by a clinician for diagnosis. The DES is a

questionnaire that measures dissociative symptoms and diagnoses based on overall score and

sub-scale results (Bernstein,1986). The CDS is used to determine the severity of

depersonalization symptoms (Sierra & Berrios, 2000).

Dissociative disorders in general are known to be founded in experiences of trauma or

abuse, but depersonalizations traumatic causes are more variable than those of

more severe dissociative disorders; Not only childhood trauma, but also later severe

stress, frightening episodes of other mental illness, and even isolated drug use can

precipitate it. In some cases, there can be no apparent trigger. (Simeon & Abugel,

2009, p.17)

Choosing a topic to research in preparation of this paper proved to be difficult. My

interest of study among social science is psychology. As stated in my five-year plan, I would like

to become a practicing psychologist. I would like to help those who suffer from anxiety. DP/DR

seems to fit within this realm and a general treatment is not known as in other anxiety disorders.

The following will summarize and critique literature read on pharmacotherapy, neurobiological

and psychotherapy treatments of depersonalization/derealization disorder, as well as examine

alternative techniques in treatment. A summary of findings and conclusion will follow.

Depersonalization/Derealization Disorder 4

Unfortunately, there were several limitations in this research. On my part, a lack of time

to invest in the project, insufficient training in psychology, and personal bias could have affected

the outcome of research. On part of the literature, there were a limited number of studies on

depersonalization/derealization disorder treatments. Access to many of these studies was not

possible due to high costs per journal article. The diagnosis of depersonalization/derealization

disorder is based off from self-reported experiences. The subjective nature of an individuals

description of symptoms may make an accurate diagnosis difficult (Simeon et al., 2015). Studies

also only report quantitative data. In depth descriptions and patient testimonials of results were

not available for analysis.

Literature Review

There are no recognized pharmacotherapy or psychological treatments for

depersonalization/derealization disorder. While clinical research on treatments for DDD appears

to be limited, there are mostly small studies and single case reports that offer possible treatment

options.

Selective serotonin reuptake inhibitors are mostly prescribed for depression and anxiety

but can be used in the treatment of depersonalization/derealization disorder. From the few studies

on SSRIs and DDD, the medication did not change the symptoms of DDD but did make the

patients feel less bothered by them. Many also reported feeling better overall. (Simeon, 2009)

After reading the studies, it is difficult to understand why SSRIs are so commonly prescribed for

depersonalization/derealization disorder. The only deductions can be that clinicians do not have

recent data or, in the absence of a recognized treatment, managing overall well-being takes

precedence.

SSRIs are the only drug treatment for depersonalization with a documented large
Depersonalization/Derealization Disorder 5

randomized trial. A few other pharmacotherapies have shown some promise and merit further

research. A clinical trial of clomipramine, a tricyclic agent that is helpful with anxiety and

obsessional disorders resulted in one complete remission and 2 close to remission (Simeon et al.,

2009). Although not generally used in the treatment of DDD, naloxone, an opioid antagonist, has

had some success. Out of a trial of 11 chronic patients, three had complete remissions and seven

reported marked improvements. A second study with the same methods found a 30% decrease in

depersonalization symptoms using three dissociation scales (Simeon et al., 2009). While it

sounds promising, the studies were small, having only 11 patients in the first and 14 patients in

the second. The studies only reported immediate results and no placebo groups were mentioned.

Lamotrigine, an anticonvulsant has conflicting data. A study in 2001 found that lamotrigine as an

add-on therapy to SSRIs brought about significant clinical improvement in all patients (Sierra

et al., 2001). This study had six patients, improvement was not clearly defined, and the study did

not involve organized treatment. It makes sense in the placebo-controlled, cross-over trial done

in 2003, yielded opposite results (Sierra et al., 2003). Although there have been remissions from

medication alone, it is most likely not enough and should be combined with psychotherapy.

In 2003, Dr. Elaine Hunter and colleagues of the Institute of Psychiatry in London formed

a model of cognitive-behavioral therapy for chronic depersonalization with the belief the

disorder has a strong correlation with anxiety. The model has 5 components: psycho-education

and normalizing, diary keeping, reducing avoidance, reducing self-focused attention, and

challenging catastrophic assumptions. A study done in 2005 was published in which 21 patients

were treated with CBT for an average of 13 sessions. At the end of the study, 30% of patients no

longer fit the diagnostic criteria for Depersonalization disorder. (Hunter et al., 2005) This model

of CBT has promise since it addresses many factors identified with possible causations of the
Depersonalization/Derealization Disorder 6

disorder. It still requires further study and possible honing on a patient-to-patient basis.

Acceptance and Commitment Therapy (ACT), a treatment of anxiety disorders, has been

recommended for the treatment of depersonalization/derealization disorder (Abugel, 2011). This

approach incorporates mindfulness into accepting unwanted experiences, in ones own presence,

and acknowledging an observer part of oneself (Abugel, 2011). Some elements like addressing

avoidance behaviors are similar to CBT, which has some empirical data on positive outcomes.

Although studies on ACT and anxiety disorders proved effective, there were no available studies

linking ACTs success in treating DDD.

There are isolated case reports describing successful treatment using psychoanalytical

therapy (Torch, 1987), behavioral therapy (Sookman & Solyom, 1978), and directive

therapy (Blue, 1979), although in the latter two reports the patients described have high

levels of comorbid psychopathology and may not be cases of primary depersonalization.

(Medford et al., 2005)

A third recent neurobiological study involving transcranial magnetic stimulation resulted

in increased arousal and reduced symptoms (Jay et al., 2014). The sample size was small in this

study, 22 participants with primary DDD with scores greater than 70 on the CDS. A placebo was

also not utilized. Again, more similar studies need to be conducted to prove this as an effective

treatment method. According to the U.S. National Institute of Health, there are two clinical trials

that are currently recruiting.

What seems to be most prevalent is that clinicians are using their own eclectic mix of

therapy modes and drug treatment based on individual case. Trial and error with each case seems

plausible since there are no standard treatments as of yet.

Depersonalization/Derealization Disorder 7

Alternative Findings

A few alternative treatments found were through chat forums for sufferers of chronic

depersonalization/derealization disorder. A few claims were made as to remission being achieved

through daily meditation and the practice of mindfulness. Another man posted that he had cured

himself through a combination of the supplements L-theanine, L-tyrosine, aniracetam, alpha

glycrylphosphorylcholine, DMAE, and phosphatidylserine. Another member of the forum

claimed it helped their remission as well. There were no mentions of any other medications or

forms of therapy used in conjunction so these claims should be taken with a grain of salt. I have

also read about ibogaine treatment. In this therapy the patient is given the hallucinogen ibogaine,

which is thought to bring out traumatic memories that cause depersonalization/derealization. The

patient proceeds to work through those memories and goes into remission. Again, forum

discussions have led to the conclusion that this substance is a possible treatment. I believe that

this experience may add trauma. Patients need to work through trauma at their own pace.

Summary/Discussion

After examining research on depersonalization/derealization disorder, it has become clear

that more studies need to be done on this disorder. Although lack of evidence-based treatment is

out there, it leaves room for exciting new developments. Results from trials on transcranial

magnetic stimulation are exceedingly anticipated. From the biopsychosocial perspective, I

question if there is just one treatment for this disorder. Especially when considering that the

causation is so highly variable, there may not be a distinct answer to treatment. The eclectic mix

of therapy that clinicians are currently implementing seems to make the most sense. Basic

guidelines are helpful but individuals are not defined by the disorder. Every case is unique and

should be treated as such.

Depersonalization/Derealization Disorder 8

This research is useful since I did not encounter any documents compiling all of these

treatment methods with critique. A few sources had drawn together some of treatments I

presented but left many I found out. Possibly because some of the information I came across is

fairly recent or not as widely recognized. I will be watching for future development in treatment.
Depersonalization/Derealization Disorder 9

References

Abugel, Jeffrey. (2011). Stranger to Myself, Inside Depersonalization: The Hidden Epidemic.

The Book Source, Inc.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,

Fourth Edition, Text Revision. American Psychiatric Association, Arlington, VA.; 2001.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,

Fifth Edition. Arlington, VA: American Psychiatric PressInc.; 2013.

Bernstein, EM, Putnam, FW. (1986). Development, Reliability, and Validity of a Dissociation

Scale. J. Nerv. Ment. Dis. 174 (12): 727-35. doi: 10.1097/00005053-198612000-00004.

Bezzubova, Elena. (2014). Depersonlization in the DSM-5. Psychology Today. Sussex

Publishers, LLC. Retrieved from http://www. Psychologytoday.com/blog/the-

search-self/201406/depersonalization-in-the-dsm-5

Gentile, J.P, Snyder, M., & Marie Gillig, P. (2014). STRESS AND TRAUMA: Psychotherapy &

Pharmacotherapy for Depersonalization/Derealization Disorder. Innovations in

Clinical Neuroscience, 11(7-8), 37-41.

Halgin, R. P., & Whitbourne, S. K. (2010). Abnormal Psychology (6 ed.). New York, NY: McGraw-Hill.

Hunter, E.C.M., Phillips, M.L., Chalder, T., Sierra, M., David, A.S. (2003). Depersonalization Disorder:

A Cognitive-Behavioral Conceptualization. Behavior Research and Therapy, 41, 1451-1467.

Retrieved from http://www.dx.doi.org.ursus-proxy-7.ursus.maine.edu/10.1016/s0005-

7967(03)00066-4

Hunter, E.C.M., Sierra, M., David, A.S. (2005). The Epidemiology of Depersonalization and

Derealization: A Systematic Review. Soc Psychiatry Epidemiology 2004; 39:9.

Jay, E., Sierra, M., Van den Eynde, F., Rothwell, J.C., David, A.S. (2014). Testing a Neurobiological
Depersonalization/Derealization Disorder 10

Model of Depersonalization Disorder Using Transcranial Magnetic Stimulation. Brain

Stimulation, Vol. 7:2, 252-259.

Medford, N., Sierra, M., Baker, D., David, A.S. (2005). Understanding and Treating

Depersonalization Disorder. Advances in Psychiatric Treatment. (2) 92-100; doi:

10.1192/apt.11.2.92

Sierra, M, Berrios, G.E. (2000). The Cambridge Depersonalization Scale: a new instrument

for the measure of depersonalization. Psychiatry Research. 93(2):153-64.

Sierra, M., Phillips, M.L., Ivin, G. (2003). A Placebo Controlled, Cross-over Trial of

Lamotrigine in Depersonalization Disorder. General Psychiatry, 59, 833-838.

Sierra, M., Phillips, M.L., Lambert, M.V. (2001). Lamotrigine in the Treatment of

Depersonalization Disorder. Journal of Clinical Psychiatry, 62, 826-827.

Simeon, D., Abugel, J. (2009). Feeling Unreal. Cary, GB: Oxford University Press, USA.

Retrieved from http://www.ebrary.com.ursus-proxy-7.ursus.maine.edu

Simeon, D., Spiegel, David, Hermann, Richard. (2015). Deperonalization/Derealization

Disorder: Epidemiology, Pathogenesis, Clinical Manifestations, Course, and

Diagnosis. Retrieved from http://www.uptodate.com/contents/depersonalization-

derealization-disorder-epidemiology-pathogenesis-clinical-manifestations-course-

diagnosis.

Wang, Philip. (2016). What Are Dissociative Disorders? American Psychiatric Association.

Retrieved from http://www.psychitatry,org/what-are-dissociative-disorders