Depersonalization in panic disorder: a clinical study

Depersonalization/derealization and its relationship to mood and anxiety disorders in the National Comorbidity Survey-Replication (NCS-R)

BACKGROUND

Depersonalization/derealization (dpdr) is known to occur across mood and anxiety disorders (MAD) and has been proposed as a marker of worse illness. However, despite the well-known clinical association, there are no epidemiological data on the relationship between dpdr and MAD.

METHOD

In this NCS-R analysis clinically significant dpdr (DPDR-C) was defined as "sometimes" or "often" past-month endorsement of depersonalization and/or derealization in the absence of other pathological dissociation. Six past-month MAD diagnoses were examined: DSM-IV generalized anxiety disorder, panic disorder, social phobia, major depression, bipolar I, and bipolar II.  RESULTS: National DPDR-C one-month prevalence was 0.9%. After excluding all cases with past-month posttraumatic stress disorder or non-dpdr pathological dissociation, 21.2% of DPDR-C cases were accounted for by MAD while 3.0% of MAD cases endorsed DPDR-C, ranging from 0% (generalized anxiety disorder) to 11.8% (comorbid mood and anxiety disorder). DPDR-C was not uniquely related to any MAD disorder, and was not associated with MAD age of onset, chronicity, or impairment. Rather, DPDR-C was significantly associated with number of comorbid MAD disorders and with mood/anxiety comorbidity.

CONCLUSION

At the epidemiologic level DPDR-C was uncommon in MAD but was more likely to occur in the presence of combined mood and anxiety disturbance, which may cause greater disruption to the usual sense of self and thus trigger unreality experiences.

Psychometric properties of the Iranian version of the dissociative experiences measure, Oxford (DEMO)

BACKGROUNDS

Dissociative experiences are described as crucial psychological mechanisms involving the organism's responses to severe psychological traumas and unpleasant past experiences. This research was conducted to examine the psychometric properties of the Dissociative Experiences Measure, Oxford (DEMO) in the Iranian general population.

METHODS

This study used cross-sectional correlation, and the statistical population consisted of Iranians over 15 years old. Among them, 712 subjects were chosen as the study sample using the convenience sampling technique. Data were acquired between February and April 2022 using DEMO, Dissociative Experiences Scale II (DES-II), and Depression Anxiety and Stress Scale (DASS-21). In order to determine DEMO's psychometric properties, Confirmatory Factor Analysis (CFA) was used to investigate the factorial structure, Cronbach's alpha analyses to examine the internal consistency reliability, and Pearson correlation analyses to examine the relationships between DEMO's subscales and the subscales of DES-II and DASS-21, indicating convergent validity. In order to analyze the data, LISREL 8.0 and SPSS-26 were used.

RESULTS

Based on the results of the CFA, the proposed five-factor structure of DEMO showed an acceptable fit to the data (χ² = 1939.81, SRMR = 0.078, CFI = 0.96, RMSEA = 0.074). The internal reliability was satisfactory for the total scale (Cronbach's alpha = 0.93) and the five subscales (Cronbach's alpha = 0.89 for unreality, 0.87 for numb and disconnected, 0.80 for memory blanks, 0.85 for zoned out, and 0.79 for vivid internal world). The CFA results indicated that the five factors explained 60.69% of the variance. Significant correlations were observed between the DEMO subscales and the respective subscales of DES-II and DASS-21, confirming the measure's convergent validity.

CONCLUSION

It can be concluded from the results of this study that the DEMO has high reliability and validity among the Iranian general population.

Impact of depersonalization on the course of depression: longitudinal observations from the gutenberg health study

BACKGROUND

Symptoms of depersonalization (DP) and derealization (DR) are a risk factor for more severe impairment, non-response to various treatments, and a chronic course. In this study, we investigated the effects of DP/DR symptoms in patients with clinically significant depressive symptoms on clinical characteristics and various outcomes in a representative population-based sample with a 5-year follow-up.

METHODS

The middle-aged sample comprised n = 10,422 persons at baseline, of whom n = 9,301 were free from depressive and DP/DR symptoms. N = 522 persons had clinically significant depression (PHQ-9 ≥ 10) and co-occurring DP/DR symptoms, and n = 599 persons had clinically significant depression (PHQ-9 ≥ 10) without DP/DR symptoms.

RESULTS

There were substantial health disparities between persons with and without depression. These disparities concerned a wide range of life domains, including lower quality of the recalled early life experiences with the parents, current socioeconomic status, social integration (partnership, loneliness), current social and interpersonal stressors (family, work), functional bodily complaints (e.g., tinnitus, migraine, chest pain), unhealthy lifestyle, and the prevalence of already developed physical diseases. These disparities persisted to the 5-year follow-up and were exceptionally severe for depressed persons with co-occurring DP/DR symptoms. Among the depressed persons, the co-occurrence of DP/DR symptoms more than doubled the risk for recurrence or persistence of depression. Only 6.9% of depressed persons with DP/DR symptoms achieved remission at the 5-year follow-up (PHQ-9 < 5). Depression with and without co-occurring DP/DR worsened self-rated physical health significantly. The impact of depression with co-occurring DP/DR on the worsening of the self-rated physical health status was stronger than those of age and major medical diseases (e.g., heart failure). However, only depression without DP/DR was associated with mortality in a hazard regression analysis adjusted for age, sex, and lifestyle.

CONCLUSIONS

The results demonstrated that DP/DR symptoms represent an important and easily assessable prognostic factor for the course of depression and health outcomes. Given the low remission rates for depression in general and depression with DP/DR in particular, efforts should be made to identify and better support this group, which is disadvantaged in many aspects of life.

Unraveling the Complexity: Exploring the Intersection of Panic Disorder, Dissociation, and Complex Post-Traumatic Stress Disorder

BACKGROUND

Patients with panic disorder (PD) may experience increased vulnerability to dissociative and anxious phenomena in the presence of repeated traumatic events, and these may be risk factors for the development of complex post-traumatic stress disorder (cPTSD). The present study aims to find out whether the presence of cPTSD exacerbates anxiety symptoms in patients suffering from panic disorder and whether this is specifically associated with the occurrence of dissociative symptoms.

METHODS

One-hundred-and-seventy-three patients diagnosed with PD were recruited and divided into two groups based on the presence (or absence) of cPTSD using the International Trauma Questionnaire (ITQ) scale. Dissociative and anxious symptoms were assessed using the Cambridge Depersonalization Scale (CDS) and Hamilton Anxiety Scale (HAM-A), respectively.

RESULTS

Significant differences in re-experienced PTSD (p < 0.001), PTSD avoidance (p < 0.001), PTSD hyperarousal (p < 0.001), and DSO dysregulation (p < 0.001) were found between the cPTSD-positive and cPTSD-negative groups. A statistically significant association between the presence of cPTSD and total scores on the HAM-A (p < 0.001) and CDS (p < 0.001) scales was found using regression analysis.

CONCLUSIONS

This study highlights the potential link between dissociative symptoms and a more severe clinical course of anxiety-related conditions in patients with PD. Early intervention programs and prevention strategies are needed.

Anxiety sensitivity, distress intolerance, and negative interpretation bias strengthen the relationship between trait anxiety and depersonalization

BACKGROUND OBJECTIVES

Depersonalization is common in anxiety disorders, but little is known about factors that influence co-occurring anxiety and depersonalization.

DESIGN

We investigated trait moderators of the relationships between state and trait anxiety and depersonalization to better understand their co-occurrence and to identify potential points of intervention.

METHODS

Adults recruited on Amazon Mechanical Turk (N = 303) completed two computer tasks designed to increase variability in state anxiety and depersonalization as well as several self-report questionnaires.

RESULTS

As hypothesized, anxiety positively predicted depersonalization at both a state level and trait level. Moreover, as hypothesized, the trait anxiety-trait depersonalization relationship was strengthened by greater anxiety sensitivity; distress intolerance; and negative interpretation bias for anxiety sensations, and for depersonalization sensations. None of these hypothesized trait moderators significantly strengthened the state anxiety-state depersonalization relationship.

CONCLUSIONS

These findings suggest that, on a trait level, anxiety and depersonalization more frequently co-occur when people catastrophically misinterpret their symptoms or have lower emotional distress tolerance.

Symptom variability in depersonalization-derealization disorder: A latent profile analysis

OBJECTIVE

Depersonalization-derealization disorder (DDD) is characterized by diverse symptomatology overlapping with anxiety and dissociative disorders, but the sources of this variability are poorly understood. This study aims to determine whether symptom heterogeneity is attributable to the presence of latent subgroups.

METHOD

We applied latent profile analysis to psychometric measures of anxiety, depersonalization-derealization, and dissociation in 303 DDD patients.

RESULTS

The analysis yielded evidence for five discrete subgroups: three of varying severity levels and two moderate-to-severe classes characterized by differential dissociative symptoms. The five classes reliably differed on several nondissociative symptoms, comorbidities, and factors precipitating their diagnosis but did not significantly differ in other symptoms including anxiety.

CONCLUSION

These results suggest the presence of three distinct DDD subtypes in the upper severity range that are distinguished by differential expression of detachment and compartmentalization symptoms. Further elucidation of these subtypes has potential implications for the etiology, mechanisms, and treatment of DDD.

Testing Clinical Intuitions About Barriers to Improvement in Cognitive-Behavioral Therapy for Panic Disorder

Although clinical intuitions influence psychotherapeutic practice and are a rich source of novel hypotheses for research, many remain to be empirically tested. This study evaluates whether clinicians' beliefs about barriers to progress in cognitive-behavioral therapy (CBT) for panic disorder are supported by data. Data from a randomized-controlled trial comparing CBT to panic-focused psychodynamic psychotherapy (PFPP) for adults with primary panic disorder (N = 161) were used to evaluate 15 factors endorsed by clinicians as impediments to CBT in a recent survey. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Hierarchical linear modeling revealed that none of the perceived barriers were predictive of poor outcome. Contrary to clinicians' intuitions, dissociation during panic attacks was associated with greater symptomatic improvement in both treatment arms (β = -0.69, p < .05), above the effect of established predictors. Moderation analyses revealed that when patients had PTSD diagnosed with the Anxiety Disorders Interview Schedule (β = 1.71, p < .05) or less severe panic disorder (β = 0.45, p = .04), they changed more rapidly in CBT than in PFPP. Overall, clinician agreement was inversely related to the strength of a predictor (r = -.24, p = .39). Although clinical intuitions can be useful as clinical and empirical signals, such beliefs should be critically examined before informing practice. Dialogue between academics and clinicians might be enhanced through research that incorporates input from front-line practitioners.

Symptoms of depersonalization/derealization are independent risk factors for the development or persistence of psychological distress in the general population: Results from the Gutenberg health study

BACKGROUND

Symptoms of depersonalization (DP) and derealization (DR) have a high prevalence in patient and community samples. Previous studies suggested that DP/DR symptoms might represent a marker of disease severity and poor prognosis. However, population-based studies investigating the impact of DP/DR symptoms on the course of depression and anxiety are sparse. Therefore, we aimed to analyze whether symptoms of DP/DR are longitudinally associated with the persistence or incidence of elevated symptoms of depression/anxiety.

METHODS

We analyzed observational data from a sample of 13.182 participants of the Gutenberg Health Study. The outcomes were elevated symptoms of depression/anxiety at the 2.5 years follow-up as determined by the 2-item depression scale (PHQ-2), the 2-item anxiety scale (GAD-2), and the compound measure PHQ-4 respectively. The predictor was the 2-item Cambridge Depersonalization Scale (CDS-2).

RESULTS

8.7% of the sample were bothered by symptoms of DP/DR at baseline. They had an increased risk for elevated symptoms of depression/anxiety at the 2.5-year follow-up beyond baseline depression/anxiety and other factors. Each point increment in the CDS-2 scale, ranging from 0-6, was associated with a 21% increase of risk for PHQ-4 ≥ 3 at the follow-up (odds ratio 1.21, 95% confidence interval 1.11-1.32).

LIMITATIONS

The study was mostly questionnaire-based.

CONCLUSION

Symptoms of DP/DR are independent risk factors for the persistence or incidence of elevated symptoms of depression/anxiety. Symptoms of DP/DR represent an easily assessable risk factor for the course of mental disorders. Treatment and prevention of mental disorders might benefit from the broader recognition of these phenomena.

Konrad A, Hoyer J. Die Cambridge Depersonalisation Scale-Situational (CDS-S) zur Erfassung von situationsabhängigem Depersonalisationserleben

Zusammenfassung. Depersonalisations- / Derealisationssymptome sind während der Konfrontation mit angstbesetzten Reizen oder Situationen häufig. Zur Erfassung dieses situationsbezogenen Depersonalisationserlebens wurde die Cambridge Depersonalisation Scale adaptiert. Die psychometrischen Gütekriterien der CDS-Situational (CDS-S) wurden in 2 Studien untersucht. 53 Patientinnen und Patienten mit Sozialer Angststörung und 32 gesunde Kontrollprobandinnen und Kontrollprobanden führten zweimal im Abstand von 4 Monaten den Trier Social Stress Test durch und schätzten anschließend die Schwere der Depersonalisation / Derealisation (CDS-S) und der Angst während des Tests ein. Ferner bearbeiteten 26 Studierende mit Prüfungsangst und 43 Studierende ohne Prüfungsangst die CDS-S direkt nach einer mündlichen Prüfung sowie 7 Tage später. Je nach Studie waren Cronbachs α (α ≥ .88), Item-Trennschärfen, Split-Half-Reliabilität ( rtt ≥ .74) und Retest-Reliabilität ( rtt = .40 – .88) zufriedenstellend bis sehr gut. Die Überprüfung der Veränderungssensitivität, Konstruktvalidität und faktoriellen Validität ergab zufriedenstellende Ergebnisse. Die CDS-S erfasste in 2 Studien situationsbezogenes Depersonalisations- / Derealisationserleben hinreichend reliabel und valide und ist zur Messung von Depersonalisations- / Derealisationssymptomen im sozialen und Leistungskontext zu empfehlen.

Developing a new measure of dissociation: The Dissociative Experiences Measure, Oxford (DEMO)

The field of dissociation is receiving increasing attention, despite a lack of coherent conceptualisation of the construct. Advances in the field would be aided by a measure that reflects service user experiences of dissociative experiences and can be easily scored. The current study describes the development of a new measure of dissociation (Dissociative Experiences Measure, Oxford; DEMO) that aims to fulfil these criteria. The study follows an exploratory, data-driven, measure development design. Resource searching and feedback from clinicians (n = 3) and service users (n = 6) were used to develop an extensive item pool. An online sample (n = 691) provided data for a factor analysis of the item pool. Factor analysis produced a measure with five subscales: 'unreality', 'numb and disconnected', 'memory blanks', 'zoned out', and 'vivid internal world'. Further analysis indicated that the new measure has high internal consistency, and high convergent, divergent, and discriminant validity. The DEMO shows promise as an up-to-date clinical and research tool for the assessment of dissociative experiences. These results are preliminary, and further validation of the measure with a clinical sample is required.

Are there advances in pharmacotherapy for panic disorder? A systematic review of the past five years

INTRODUCTION

Several effective medications are available for treating panic disorder (PD). However, outcomes are unsatisfactory in a number of patients, suggesting the usefulness of expanding the array of antipanic drugs and improving the quality of response to current recommended treatments.

AREAS COVERED

The authors have performed an updated systematic review of pharmacological studies (phase III onwards) to examine whether advances have been made in the last five years. Only four studies were included. D-cycloserine no longer seemed promising as a cognitive-behavioral therapy (CBT) enhancer. Some preliminary findings concerning the optimization of recommended medications deserved consideration, including: the possibility that SSRIs are more effective than CBT alone in treating panic attacks, combined therapy is preferable when agoraphobia is present, and clonazepam is more potent than paroxetine in decreasing panic relapse.

EXPERT OPINION

Given the lack of novel treatments, expanding a personalized approach to the existing medications seems to be the most feasible strategy to improve pharmacotherapy outcomes regarding PD. Recent technological progress, including wearable devices collecting real-time data, 'big data' platforms, and application of machine learning techniques might help make outcome prediction more reliable. Further research on previously promising novel treatments is also recommended.

Depersonalisation disorder: clinical features of 204 cases

Background

Depersonalisation disorder is a poorly understood and underresearched syndrome.

Aims

To carry out a large and comprehensive clinical and psychopathological survey of a series of patients who made contact with a research clinic.

Method

A total of 204 consecutive eligible referrals were included: 124 had a full psychiatric examination using items of the Present State Examination to define depersonalisation/derealisation and 80 had either a telephone interview (n=22) or filled out a number of self-report questionnaires. Cases assessed were diagnosed according to DSM–IV criteria.

Results

The mean age of onset was 22.8 years; early onset was associated with greater severity There was a slight male preponderance. The disorder tended to be chronic and persistent. Seventy-one per cent met DSM–IV criteria for primary depersonalisation disorder. Depersonalisation symptom scores correlated with both anxiety and depression and a past history of these disorders was commonly reported. ‘Dissociative amnesia’ was not prominent.

Conclusions

Depersonalisation disorder is a recognisable clinical entity but appears to have significant comorbidity with anxiety and depression. Research into its aetiology and treatment is warranted.

Reduction of depersonalization during social stress through cognitive therapy for social anxiety disorder: A randomized controlled trial

Symptoms of depersonalization during feared social situations are commonly experienced by individuals with social anxiety disorder (SAD). Despite its clinical relevance, it is not addressed in standard treatment manuals and it remains unclear if depersonalization is reduced by well-established treatments. This study investigated whether cognitive therapy (CT) for SAD effectively reduces depersonalization and whether pre-treatment severity of depersonalization predicts or mediates treatment outcome. In a randomized controlled trial, patients underwent the standardized Trier Social Stress Test before and after CT (n=20) or a waitlist period (n=20) and were compared to healthy controls (n=21). Self-reported depersonalization was measured immediately after each stress test. Depersonalization significantly decreased following CT, especially in treatment responders (η_p²=0.32). Pre-treatment depersonalization did neither predict nor mediate post-treatment severity of social anxiety. Further prospective studies are needed for a better scientific understanding of this effect. It should be scrutinized whether SAD-patients suffering from depersonalization would benefit from a more specific therapy.

Psychological factors and treatment effectiveness in resistant anxiety disorders in highly comorbid inpatients

BACKGROUND

Anxiety disorders are a group of various mental syndromes that have been related with generally poor treatment response. Several psychological factors may improve or hinder treatment effectiveness. Hope has a direct impact on the effectiveness of psychotherapy. Also, dissociation is a significant factor influencing treatment efficiency in this group of disorders. Development of self-stigma could decrease treatment effectiveness, as well as several temperamental and character traits. The aim of this study was to explore a relationship between selected psychological factors and treatment efficacy in anxiety disorders.

SUBJECTS AND METHODS

A total of 109 inpatients suffering from anxiety disorders with high frequency of comorbidity with depression and/or personality disorder were evaluated at the start of the treatment by the following scales: the Mini-International Neuropsychiatric Interview, the Internalized Stigma of Mental Illness scale, the Adult Dispositional Hope Scale, and the Temperament and Character Inventory - revised. The participants, who sought treatment for anxiety disorders, completed the following scales at the beginning and end of an inpatient-therapy program: Clinical Global Impression (objective and subjective) the Beck Depression Inventory - second edition, the Beck Anxiety Inventory, and the Dissociative Experiences Scale. The treatment consisted of 25 group sessions and five individual sessions of cognitive behavioral therapy or psychodynamic therapy in combination with pharmacotherapy. There was no randomization to the type of group-therapy program.

RESULTS

Greater improvement in psychopathology, assessed by relative change in objective Clinical Global Impression score, was connected with low initial dissociation level, harm avoidance, and self-stigma, and higher amounts of hope and self-directedness. Also, individuals without a comorbid personality disorder improved considerably more than comorbid patients. According to backward-stepwise multiple regression, the best significant predictor of treatment effectiveness was the initial level of self-stigma.

CONCLUSION

The initial higher levels of self-stigma predict a lower effectiveness of treatment in resistant-anxiety-disorder patients with high comorbidity with depression and/or personality disorder. The results suggest that an increased focus on self-stigma during therapy could lead to better treatment outcomes.

Personality features, dissociation, self-stigma, hope, and the complex treatment of depressive disorder

OBJECTIVE

Identifying the predictors of response to psychiatric and psychotherapeutic treatments may be useful for increasing treatment efficacy in pharmacoresistant depressive patients. The goal of this study was to examine the influence of dissociation, hope, personality trait, and selected demographic factors in treatment response of this group of patients.

METHODS

Pharmacoresistant depressive inpatients were enrolled in the study. All patients completed Clinical Global Impression - both objective and subjective form (CGI), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI) at baseline and after 6 weeks of combined pharmacotherapy and psychotherapy (group cognitive-behavioral or group psychodynamic) treatment as an outcome measures. The Internalized Stigma of Mental Illness Scale (ISMI), Dissociative Experience Scale (DES), Adult Dispositional Hope Scale (ADHS), and Temperament and Character Inventory (TCI-R) were completed at the start of the treatment with the intention to find the predictors of treatment efficacy.

RESULTS

The study included 72 patients who were hospitalized for the pharmacoresistant major depression; 63 of them completed the study. The mean scores of BDI-II, BAI, subjCGI, and objCGI significantly decreased during the treatment. BDI-II relative change statistically significantly correlated with the total ISMI score, Discrimination Experience (ISMI subscale), and Harm Avoidance (TCI-R personality trait). According to stepwise regression, the strongest factors connected to BDI-II relative change were the duration of the disorder and Discrimination Experience (domain of ISMI). ObjCGI relative change significantly correlated with the level of dissociation (DES), the total ISMI score, hope in ADHS total score, and Self-Directedness (TCI-R). According to stepwise regression, the strongest factor connected to objCGI relative change was Discrimination Experience (domain of ISMI). The existence of comorbid personality disorder did not influence the treatment response.

CONCLUSION

According to the results of the present study, patients with pharmacoresistant depressive disorders, who have had more experience with discrimination because of their mental struggles, showed a poorer response to treatment.

Coping strategies, hope, and treatment efficacy in pharmacoresistant inpatients with neurotic spectrum disorders

BACKGROUND

Approximately 30%-60% of patients with neurotic spectrum disorders remain symptomatic despite treatment. Identifying the predictors of good response to psychiatric and psychotherapeutic treatment may be useful for increasing treatment efficacy in neurotic patients. The objective of this study was to investigate the influence of hope, coping strategies, and dissociation on the treatment response of this group of patients.

METHODS

Pharmacoresistant patients, who underwent a 6-week psychotherapeutic program, were enrolled in the study. All patients completed the Clinical Global Impression (CGI) - both objective and subjective forms, Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI)-II at baseline and after 6 weeks. The COPE Inventory, the Adult Dispositional Hope Scale (ADHS), and the Dissociative Experiences Scale (DES) were completed at the start of the treatment.

RESULTS

Seventy-six patients completed the study. The mean scores for all scales measuring the severity of the disorders (BAI, BDI-II, subjective and objective CGI) significantly decreased during the treatment. Several subscores of the COPE Inventory, the overall score of ADHS, and the overall score of DES significantly correlated with the treatment outcome. Multiple regression was used to find out which factors were the most significant predictors of the therapeutic outcomes. The most important predictors of the treatment response were the overall levels of hope and dissociation.

CONCLUSION

According to our results, a group of patients with a primary neurotic disorder, who prefer the use of maladaptive coping strategies, feel hopelessness, and have tendencies to dissociate, showed poor response to treatment.

Hypnosis aided fixed role therapy for social phobia: a case report

This case study details how hypnosis aided fixed role therapy (HAFRT) was employed in the successful treatment of a case of social phobia with a history of refractory outcomes to previous therapy trials. The treatment consisted of 10 office sessions, scheduled every two weeks, of HAFRT along with twice a day self-hypnotic sessions where the patient performed multiple visualization rehearsals of the vignettes that were successfully mastered in hypnosis during office visits. The results indicated that this patient was able to engage in social and professional affairs that were impossible prior to treatment. The patient retained the therapy gains at follow up 6 months later.

Anxiety changes depersonalization and derealization symptoms in vestibular patients

Background. Depersonalization and derealization are common symptoms reported in the general population. Objective. The aim of the present study was to establish the relationship between anxiety and depersonalization and derealization symptoms in patients with peripheral vestibular disorders. Methods. Twenty-four vestibular patients with anxiety and 18 vestibular patients without anxiety were examined for depersonalization and derealization symptoms. They were also compared to healthy controls. Results. The results revealed that anxiety consistently changes depersonalization and derealization symptoms in vestibular patients. They are more frequent, more severe, and qualitatively different in vestibular patients with anxiety than in those without anxiety. Conclusion. Anxiety has an effect on depersonalization and derealization symptoms in vestibular patients. The various hypotheses about the underlying mechanism of this effect were discussed.

I-95 phobia treated with hypnotic systematic desensitization: a case report

Systematic desensitization and hypnosis mediated therapy share empirical evidence of efficacy in the treatment of specific phobias. However, a review of the literature indicated there is limited documentation in the employment of these modalities for treating driving related phobias (DRP). This article reports on the use of hypnosis aided systematic desensitization (HASD) in the successful treatment of a case of non-accident related driving phobia, specifically manifested on Interstate 95 (I-95). The treatment consisted of 6 office sessions of HASD along with 14 in-vivo sessions where the patient performed multiple exposures/rehearsals of the behaviors that had been successfully mastered at the office visits. The results indicated that this patient with case of (DRP) was able to resume travel on I-95 at conclusion of treatment. The patient was symptom free at follow up 6 months later.

Depersonalization/derealization during acute social stress in social phobia

The present study aimed at investigating how frequently and intensely depersonalization/derealization symptoms occur during a stressful performance situation in social phobia patients vs. healthy controls, as well as testing hypotheses about the psychological predictors and consequences of such symptoms. N=54 patients with social phobia and N=34 control participants without mental disorders were examined prior to, during, and after a standardized social performance situation (Trier Social Stress Test, TSST). An adapted version of the Cambridge Depersonalization Scale was applied along with measures of social anxiety, depression, personality, participants' subjective appraisal, safety behaviours, and post-event processing. Depersonalization symptoms were more frequent in social phobia patients (92%) than in controls (52%). Specifically in patients, they were highly positively correlated with safety behaviours and post-event-processing, even after controlling for social anxiety. The role of depersonalization/derealization in the maintenance of social anxiety should be more thoroughly recognized and explored.

A Preliminary Evaluation of Repeated Exposure for Depersonalization and Derealization

Dissociative symptoms including depersonalization and derealization are commonly experienced by individuals suffering from panic disorder or posttraumatic stress disorder (PTSD). Few studies have been published investigating the specific treatment of these symptoms in individuals diagnosed with panic disorder or PTSD, despite evidence that the subset of individuals with panic disorder who experience depersonalization and derealization report more panic attacks as well as greater panic severity and functional impairment. Furthermore, it has been shown that these symptoms can impede treatment and recovery in PTSD. Finally, recent research has shown that interoceptive exposure generally enhances the efficacy of treatment outcome for PTSD and PTSD with comorbid panic. This study investigated the use of a novel interoceptive exposure technique for treatment of depersonalization and derealization in individuals with high anxiety sensitivity and/or symptoms of PTSD. Results indicated significant reductions on six of seven items as well as total score on an outcome measure of depersonalization and derealization. Thus, this technique appears to hold promise for utilization as a form of interoceptive exposure in the treatment of these symptoms.

An explorative study on metacognition in obsessive-compulsive disorder and panic disorder

OBJECTIVE

To test the hypothesis that dysfunctional metacognitions might be a general vulnerability factor for anxiety disorder, metacognitive beliefs among patients with obsessive-compulsive disorder (OCD), patients with panic disorder (PD), and healthy subjects (HS) were studied. Correlations between metacognitive beliefs, OCD, and PD symptoms were also investigated.

METHODS

Patients with OCD (n = 114), patients with PD (n = 119), and HS (n = 101) were assessed with the Metacognition Questionnaire (MCQ).

RESULTS

Patients with OCD and those with PD scored significantly higher than HS on the MCQ in 2 dimensions: negative beliefs about worry concerning uncontrollability and danger as well as beliefs about the need to control thoughts dimensions. No difference in MCQ scores was observed between the OCD and PD groups. The former 2 MCQ dimensions were positively correlated with the degree of indecisiveness in patients with OCD, whereas the MCQ negative beliefs about worry positively correlated with the average intensity of anticipatory anxiety in patients with PD.

CONCLUSIONS

The presence of dysfunctional metacognitions in both patients with OCD and those with PD suggests that such beliefs can represent not only generic vulnerability factors for anxiety disorders but also elements that contribute to maintaining the disorder, as evidenced by their associations with aspects of OCD and PD symptoms.

Depersonalization and personality in panic disorder

BACKGROUND

Prevalence and clinical correlates of depersonalization symptoms have been associated with panic disorder. Personality traits might increase the likelihood of experiencing depersonalization symptoms or depersonalization disorder in panic patients.

AIMS

The objectives of this study are to establish the prevalence of depersonalization symptoms during the panic attack and in depersonalization disorder and to examine the personality factors associated with the presence of depersonalization in patients with panic disorder.

METHODS

The sample comprised 104 consecutive adult outpatients with panic disorder, diagnosed according to the Semistructured Clinical Interview for DSM-IV (Axis I/II disorders). Participants were assessed with the Cambridge Depersonalization Scales, the Temperament and Character Inventory, and the Panic and Agoraphobia Scale.

RESULTS

Forty-eight percent of the sample had depersonalization symptoms during the panic attack, whereas 20% of patients had a depersonalization disorder. Women presented more depersonalization disorders than did men (P = .036). Patients with panic disorder with depersonalization disorder had a more severe panic disorder (P = .002). Logistic regression analysis showed that self-transcendence trait (odds ratio, 1.089; 95% confidence interval, 1.021-1.162; P = .010) and severity of panic (odds ratio, 1.056; 95% confidence interval, 1.005-1.110; P = .032) were independently associated with depersonalization disorder.

CONCLUSIONS

A high prevalence of depersonalization symptoms and depersonalization disorder was confirmed in patients with panic disorder, supporting a dosage effect model for understanding depersonalization pathology. Self-transcendence trait and severity of panic disorder were reported as risk factors for depersonalization disorder.

ECEM (Eye Closure, Eye Movements): application to depersonalization disorder

Eye Closure, Eye Movements (ECEM) is a hypnotically-based approach to treatment that incorporates eye movements adapted from the Eye Movement Desensitization and Reprocessing (EMDR) protocol in conjunction with hypnosis for the treatment of depersonalization disorder. Depersonalization Disorder has been differentiated from post-traumatic stress disorders and has recently been conceptualized as a subtype of panic disorder (Baker et al., 2003; David, Phillips, Medford, & Sierra, 2004; Segui et. al., 2000). During ECEM, while remaining in a hypnotic state, clients self-generated six to seven trials of eye movements to reduce anticipatory anxiety associated with depersonalization disorder. Eye movements were also used to process triggers that elicited breath holding, often followed by episodes of depersonalization. Hypnotic suggestions were used to reverse core symptoms of depersonalization, subjectively described as "feeling unreal" (Simeon et al., 1997).

Cognitive-affective neuroscience of depersonalization

Depersonalization disorder (DPD) is characterized by a subjective sense of detachment from one's own being and a sense of unreality. An examination of the psychobiology of depersonalization symptoms may be useful in understanding the cognitive-affective neuroscience of embodiment. DPD may be mediated by neurocircuitry and neurotransmitters involved in the integration of sensory processing and of the body schema, and in the mediation of emotional experience and the identification of feelings. For example, DPD has been found to involve autonomic blunting, deactivation of sub-cortical structures, and disturbances in molecular systems in such circuitry. An evolutionary perspective suggests that attenuation of emotional responses, mediated by deactivation of limbic structures, may sometimes be advantageous in response to inescapable stress.

[Depersonalisation/derealization - clinical picture, diagnostics and therapy]

The present state of knowledge about depersonalization (DP) and derealization (DR) is reviewed with respect to classification, epidemiology, etiology, and therapy. Mild and transient DP-DR are considered to be common phenomena. The prevalence of depersonalization-derealization disorder (DP-DR-D) is estimated to be approx. 1-2% of the general population in the Western hemisphere. DP-DR-D is probably severely underdiagnosed. DP-DR-D is strongly associated with depression and anxiety disorders. It is suggested that symptoms of DP-DR indicate disease severity and negatively predict therapy outcome. Neurobiological and psychological models have shown that a disordered body schema and emotional and autonomic blunting are essential components of the disorder. Despite the frequency of DPDR and its clinical relevance, there is a considerable lack of empirical research on DP-DR with respect to the health-care situation of depersonalized patients and with regard to treatment options.

Clinical correlates of depersonalization symptoms in patients with bipolar disorder

BACKGROUND

Prevalence and clinical correlates of dissociative symptoms in general, and depersonalization (DP) in particular, in patients with mood disorders have received limited attention in the literature. Nevertheless, the identification of these symptoms may have important implications in terms of a better definition of clinical endophenotypes. Thus, this study aimed at investigating frequency and clinical correlates of dissociative symptoms, with special attention to DP symptoms, in patients with bipolar disorder (BD) looking specifically at differences between BD-I and BD-II and the comorbidity with panic disorder.

METHODS

The study sample included 91 adult patients with BD (BD-I=43; BD-II=48) assessed with the Semi-structured Clinical Interview for Temperament (TEMPS-I), the Dissociative Experiences Scale (DES) and the Structured Clinical Interview for Depersonalization-Derealization Spectrum (SCI-DER).

RESULTS

There was no difference in lifetime dissociative experiences or DP symptoms between BD-I and BD-II patients. There was no difference in relation to temperament characteristics. Lifetime DP symptoms, as assessed with the SCI-DER, were associated to an early onset of the BD (beta=-0.436, t=-4.572, p<0.001). Derealization symptoms correlated with panic disorder comorbidity (OR=1.22; 95%CI=1.03-1.46, Wald=5.177, p=0.023).

CONCLUSIONS

Our study suggests that lifetime DP symptoms are correlated with an early onset of the BD and derealization symptoms with panic disorder comorbidity, bearing the opportunity to identify patients with a specific profile for a better clinical and neurobiological definition.

The structure of lifetime panic-agoraphobic spectrum

The heterogeneity of the clinical presentation of panic disorder (PD) has prompted researchers to describe different subtypes of PD, on the basis of the observed predominant symptoms constellation. Starting from a dimensional approach to panic disorder, an instrument to assess lifetime panic-agoraphobic spectrum (PAS) available in interview or self-report form (SCI-PAS, PAS-SR) was developed which proved to have sound psychometric properties and the ability to predict delayed response to treatment in patients with mood disorders. However, the structure of the instrument was defined a priori and an examination of its empirical structure is still lacking. Aim of the present report is to analyse the factor structure of the PAS taking advantage of a large database of subjects with panic disorders (N=630) assessed in the framework of different studies. Using a classical exploratory factor analysis based on a tetrachoric correlation matrix and oblique rotation, 10 factors were extracted, accounting overall for 66.3% of the variance of the questionnaire: panic symptoms, agoraphobia, claustrophobia, separation anxiety, fear of losing control, drug sensitivity and phobia, medical reassurance, rescue object, loss sensitivity, reassurance from family members. The first two factors comprise the DSM-IV criteria for panic disorder and agoraphobia. The other factors had received limited empirical support to date. We submit that these symptoms profiles might be clinically relevant for tailoring drug treatments or psychotherapeutic approaches to specific needs. Future perspectives might include the use of these factors to select homogeneous subgroups of patients for brain-imaging studies and to contribute to elucidating the causes and pathophysiology of panic disorder at molecular level.

Short-term full kindling of the amygdala dissociates natural and periaqueductal gray-evoked flight behaviors of the rat

Panic attacks present a high comorbidity with agoraphobia, separation anxiety and generalized anxiety disorder. Nevertheless, while panic attacks have been frequently equated to fear, the relationship of panic disorder with specific phobias remains uncertain. The combination of experimental models of panic and phobias could but afford valuable information about both the comorbidity and causation of these disorders. As it regards, while the defensive behaviors produced by stimulation of dorsal periaqueductal gray matter (DPAG) resemble a panic attack, resistance to capture (RC) behaviors that ensue the kindling of the amygdala (AMY) are reminiscent of a phobic reaction. Therefore, this study examined the thresholds of DPAG-evoked panic-like behaviors in rats showing RC behaviors. Rats bearing electrodes in the DPAG and right AMY were subjected to either the full- (Kin-F) or sham- (Kin-S) kindling of AMY. RC behaviors were evaluated throughout both kindling procedures. Thresholds of DPAG-evoked defensive behaviors were recorded before and after the kindling. Moreover, performances of Kin-F and Kin-S rats in the elevated plus-maze were compared to those of intact controls. Data showed that Kin-F and Kin-S rats perform similarly in the elevated plus-maze, thereby making AMY-kindled rats unlikely as a model of generalized anxiety disorder. On the other hand, whereas the RC is characterized by a marked facilitation of natural freezing and flight behaviors, DPAG-evoked freezing (immobility and exophthalmus) and flight (galloping) behaviors were unexpectedly attenuated. Data suggest that RC is mediated by circuits distinct from those of DPAG-evoked defensive behaviors. Consequently, panic and phobic attacks may be mediated by different mechanisms as well.

The neurobiology and clinical significance of depersonalization in mood and anxiety disorders: a critical reappraisal

Depersonalization and derealization occur on a continuum of situations, from healthy individuals to a severely debilitating disorder where the symptoms can persist chronically. Since 1960s, different neurobiological models have been hypothesized and they have been associated with the temporal lobes. Recent advances in the functioning of the limbic system and the application of Geschwind's concept of disconnection in the cortico-limbic networks, pointed the role of the amygdala and its connections with medial prefrontal cortex and anterior cingulate cortex, the same structures that are strictly interlinked with the neurobiology of emotions and affective disorders. In this paper, we hypothesize that depersonalization may represent a clinical index of disease severity, poorer response to treatment and high level of comorbidity, in mood and anxiety disorders, discussing the neurobiology of depersonalization and the available clinical evidence.

Emotional memory in depersonalization disorder: a functional MRI study

This study examines emotional memory effects in primary depersonalization disorder (DPD). A core complaint of DPD sufferers is the dulling of emotional responses, and previous work has shown that, in response to aversive stimuli, DPD patients do not show activation of brain regions involved in normal emotional processing. We hypothesized that DPD sufferers would not show the normal emotional enhancement of memory, and that they would not show activation of brain regions concerned with emotional processing during encoding and recognition of emotional verbal material. Using fMRI, 10 DPD patients were compared with an age-matched healthy control group while performing a test of emotional verbal memory, comprising one encoding and two recognition memory tasks. DPD patients showed significantly enhanced recognition for overtly emotive words, but did not show enhancement of memory for neutral words encoded in an emotive context. In addition, patients did not show activation of emotional processing areas during encoding, and exhibited no substantial difference in their neural responses to emotional and neutral material in the encoding and emotional word recognition tasks. This study provides further evidence that patients with DPD do not process emotionally salient material in the same way as healthy controls, in accordance with their subjective descriptions of reduced or absent emotional responses.

Depersonalisation/derealisation symptoms in vestibular disease

BACKGROUND

Depersonalisation is a subjective experience of unreality and detachment from the self often accompanied by derealisation; the experience of the external world appearing to be strange or unreal. Feelings of unreality can be evoked by disorienting vestibular stimulation.

OBJECTIVE

To identify the prevalence of depersonalisation/derealisation symptoms in patients with peripheral vestibular disease and experimentally to induce these symptoms by vestibular stimulation.

METHODS

121 healthy subjects and 50 patients with peripheral vestibular disease participated in the study. For comparison with the patients a subgroup of 50 age matched healthy subjects was delineated. All completed (1) an in-house health screening questionnaire; (2) the General Health Questionnaire (GHQ-12); (3) the 28-item depersonalisation/derealisation inventory of Cox and Swinson (2002). Experimental verification of "vestibular induced" depersonalisation/derealisation was assessed in 20 patients and 20 controls during caloric irrigation of the labyrinths.

RESULTS

The frequency and severity of symptoms in vestibular patients was significantly higher than in controls. In controls the most common experiences were of "déjà vu" and "difficulty in concentrating/attending". In contrast, apart from dizziness, patients most frequently reported derealisation symptoms of "feel as if walking on shifting ground", "body feels strange/not being in control of self", and "feel 'spacey' or 'spaced out'". Items permitted discrimination between healthy subjects and vestibular patients in 92% of the cases. Apart from dizziness, caloric stimulation induced depersonalisation/derealisation symptoms which healthy subjects denied ever experiencing before, while patients reported that the symptoms were similar to those encountered during their disease.

CONCLUSIONS

Depersonalisation/derealisation symptoms are both different in quality and more frequent under conditions of non-physiological vestibular stimulation. In vestibular disease, frequent experiences of derealisation may occur because distorted vestibular signals mismatch with the other sensory input to create an incoherent frame of spatial reference which makes the patient feel he or she is detached or separated from the world.

Narcissistic regulation of the self and interpersonal problems in depersonalized patients

BACKGROUND

Psychoanalytical theories coincide in understanding depersonalization (DP) as a disorder of narcissistic self-regulation. DP is described as an ego defense against overwhelming shame resulting in a splitting of an observing ego detached from the experiencing self. In contrast to a behavioral-cognitive theory on DP, which suggests that the catastrophic appraisal of normal transient DP maintains the disorder, psychodynamic approaches stress that DP is an important defensive function for the individual. We examine this psychodynamic aspect more closely as it relates to narcissistic self-regulation and interpersonal behavior in depersonalized patients.

SAMPLING AND METHODS

Thirty-five patients with pathological DP are compared with 28 patient controls concerning their narcissistic self-regulation and interpersonal behavior. For the assessment, we used the German Narcissism Inventory and the Inventory of Interpersonal Problems. The two groups were controlled for sociodemographic data, comorbidity with a personality disorder, and the General Severity Index of the Symptom Check List-90-R.

RESULTS

Bonferroni-corrected group comparison showed that the depersonalized patients are characterized by perceiving themselves as helpless, hopeless, socially isolated and worthless, perceiving others as bad and disappointing, and that they avoid interpersonal relations and reality significantly more than other patients with equal symptom severity.

CONCLUSIONS

Treatment approaches on DP should take the issue of low self-esteem, pervasive shame and the related defensive social avoidance into account. Further empirical research on psychodynamic concepts of DP is warranted also for the sake of linking modern neurobiological findings with clinical experience.

Die Erfassung des Depersonalisations- Derealisationssyndroms mit dem Fragebogen zu Dissoziativen Symptoment

OBJECTIVES

The goal of this study is to investigate the applicability of the German adaptation of the Dissociative Experiences Scale, the "Fragebogen zu dissoziativen Symptomen (FDS)", for research on depersonalization (DP) and derealization (DR), and to elucidate the phenomenology of DP / DR.

METHODS

101 consecutively recruited inpatients were diagnosed with the German version of the Structured Clinical Interview for DSM-IV Dissociative Disorders for depersonalization/derealization. Furthermore, the FDS and the SCL-90-R were administered.

RESULTS

47 of 101 Patients were diagnosed with pathological DP / DR. The mean score of the DES scale of the FDS was 32.00 +/- 15.52. A cut-off score of 17.5 for the DES scale of the FDS yielded a 83.0 % sensitivity and 77.8 % specificity. Depressive disorders, anxiety disorders and trauma-associated disorders were the most common comorbidity.

CONCLUSIONS

The findings are comparable to the Anglo-American samples. The FDS was found to be quite effective for screening of DP / DR. The three-factor solution of the FDS was not well supported in this sample.

Depersonalisation disorder: a cognitive–behavioural conceptualisation

Depersonalisation (DP) and derealisation (DR) are subjective experiences of unreality in, respectively, one's sense of self and the outside world. These experiences occur on a continuum from transient episodes that are frequently reported in healthy individuals under certain situational conditions to a chronic psychiatric disorder that causes considerable distress (depersonalisation disorder, DPD). Despite the relatively high rates of reporting these symptoms, little research has been conducted into psychological treatments for this disorder. We suggest that there is compelling evidence to link DPD with the anxiety disorders, particularly panic. This paper proposes that it is the catastrophic appraisal of the normally transient symptoms of DP/DR that results in the development of a chronic disorder. We suggest that if DP/DR symptoms are misinterpreted as indicative of severe mental illness or brain dysfunction, a vicious cycle of increasing anxiety and consequently increased DP/DR symptoms will result. Moreover, cognitive and behavioural responses to symptoms such as specific avoidances, 'safety behaviours' and cognitive biases serve to maintain the disorder by increasing awareness of the symptoms, heightening the perceived threat and preventing disconfirmation of the catastrophic misinterpretations. A coherent model facilitates the development of potentially effective cognitive and behavioural interventions.

Acute stress disorder: a synthesis and critique

The diagnosis of acute stress disorder (ASD) was introduced to describe initial trauma reactions that predict chronic posttraumatic stress disorder (PTSD). This review outlines and critiques the rationales underpinning the ASD diagnosis and highlights conceptual and empirical problems inherent in this diagnosis. The authors conclude that there is little justification for the ASD diagnosis in its present form. The evidence for and against the current emphasis on peritraumatic dissociation is discussed, and the range of biological and cognitive mechanisms that potentially mediate acute trauma response are reviewed. The available evidence indicates that alternative means of conceptualizing acute trauma reactions and identifying acutely traumatized people who are at risk of developing PTSD need to be considered.