Elaine Hunter

The epidemiology of depersonalisation and derealisation - A systematic review

Abstract.Background:Symptoms of depersonalisation (DP) and derealisation (DR) are increasingly recognised in both clinical and non-clinical settings, but their importance and underlying pathophysiology is only now being addressed.Methods:This paper is a systematic review of the current state of knowledge about the prevalence of depersonalisation and derealisation using computerised databases and citation searches. All potential studies were examined and numerical data included. Three categories of study are reviewed: questionnaire and interview surveys of selected student and non-clinical samples; population-based community surveys using standardised diagnostic interviews; and clinical surveys of depersonalisation/derealisation symptoms occurring within inpatients with psychiatric disorders. In addition, we present newly analysed data of the prevalence of depersonalisation/derealisation from five large population-based studies.Results:Epidemiological surveys demonstrate that transient symptoms of depersonalisation/derealisation in the general population are common, with a lifetime prevalence rate of between 26 and 74% and between 31 and 66% at the time of a traumatic event. Community surveys employing standardised diagnostic interviews reveal rates of between 1.2 and 1.7 % for one month prevalence in a UK sample and a 2.4% current prevalence rate in a Canadian sample. Current prevalence rates in samples of consecutive inpatient admissions are reported between 1 and 16%, although screening measures employed may have resulted in these being an underestimate. Prevalence rates in clinical samples of specific psychiatric disorders vary between 30% of war veterans with PTSD and 60% of those with unipolar depression. There is a high prevalence within panic disorder with rates varying from 7.8 to 82.6%.Discussion:DP and DR symptoms are common in normal and psychiatric populations, but prevalence estimates are hampered by inconsistent definitions and the use of variable time-frames. Population-based surveys using diagnostic interviews yield prevalence rates of clinically significant DP/DR in the region of 1–2%. Surveys of clinical populations in which common screening and assessment instruments were used also yield consistently high prevalence rates. The use of reliable diagnostic assessments and rating scales is needed. The relationship between DP/DR and certain other psychiatric disorders (e. g. panic) suggests possible common pathophysiological or aetiological factors.

Intrusive memories in depression: an index of schema activation?

A sample of 31 male and female depressed patients was interviewed to investigate spontaneous, intrusive memories of immediate and past life events. Previous findings that depressed patients experience high frequency intrusive memories were confirmed, as was an association between intrusive memories of childhood abuse and severity of depression. Patients reported intrusive memories for a variety of other events, particularly involving illness and death. Limited support was obtained for the hypotheses that the course of depression would be related to the activation of negative memories, and that immediate life events would trigger the activation of memories of similar events from the past.

SHAME, EARLY ABUSE, AND COURSE OF DEPRESSION IN A CLINICAL SAMPLE: A PRELIMINARY STUDY

This study of 35 depressed patients was designed to replicate findings from a community sample of a relationship between childhood abuse and bodily shame, and bodily shame and chronic or recurrent depression. In addition, we investigated whether characterological and behavioural shame would also be related to early abuse and depression course. The relation between bodily shame and childhood abuse was replicated. When the other types of shame were considered, bodily shame was the most powerful correlate of early abuse, with behavioural shame showing no relationship. However, all three types of shame appeared to be related to chronic or recurrent course of depression.

Prevalence and childhood antecedents of depersonalization syndrome in a UK birth cohort

PurposeDepersonalization syndrome is characterised by a sense of unreality about the self [depersonalization (DP)] and/or the outside world [derealization (DR)]. Prevalence estimates vary widely. Little is known about childhood antecedents of the disorder although emotional abuse is thought to play a role.MethodsLongitudinal data from 3,275 participants of a UK population-based birth cohort (the MRC National Survey of Health and Development) were used to: (1) assess the prevalence of DP syndrome at age 36, measured by the Present State Examination (PSE); and (2) examine the effects of a range of socio-demographic, childhood adversity and emotional responses as potential risk factors for DP.ResultsThirty three survey members were classified with DP, yielding a prevalence of 0.95% [95% confidence intervals (CI) 0.56–1.34]. There were no associations with socio-economic status, parental death or divorce; self-reported accidents, childhood depression, tendency to daydream or reactions to criticism. However, teacher-estimated childhood anxiety was a strong independent predictor of adult depersonalization, and there were strong cross-sectional relationships between DP and anxiety and depression caseness.ConclusionsTo our knowledge this is the first study assessing nationwide prevalence of the DP syndrome and uses longitudinal data to explore childhood risk factors for adult DP. The prevalence of adult DP was slightly lower than reported by other surveys. The study found that childhood anxiety was the only significant predictor of the adult DP syndrome, supporting the view that depersonalisation disorder forms part of the spectrum of responses to anxiety.

Visual imagery and depersonalisation.

Twenty-eight people diagnosed with depersonalisation disorder (DD) were assessed using self-report measures of imagery ability in relation to a range of symptoms and in comparison with age- and sex-matched controls. It was found that symptoms of depersonalisation as well as other dissociative symptoms and depressed mood correlated with impaired ability to generate visual images. This was particularly evident with images pertaining to the self and other people as opposed to objects. A subgroup of 10 patients was tested on a neuropsychological battery of visual perception tests and found to be unimpaired compared with normal controls and patients with obsessive compulsive disorder, despite subjective impairments in imagery and high symptom scores. The findings add further weight to the distinctions made between imagery and perceptual processes.

Poster Session Abstracts

A random sample of therapists (N=161) working in the field of trauma were surveyed to study levels of stress. Therapists were assessed on measures of general life stress, burnout, and traumatic stress. Twenty-four percent were experiencing high levels of general life stress, 16% reported high levels of emotional exhaustion, 26% felt ineffective in terms of personal accomplishment at work and 14% were experiencing high levels of traumatic stress similar to clients with post traumatic stress disorder. Relationships between measures and demographic variables were reported, a profile of traumatised therapists was identified, and implications of these findings of therapists were presented.

Emotional memory and perception of emotional faces in patients suffering from depersonalization disorder.

Previous work has shown that patients with depersonalization disorder (DPD) have reduced physiological responses to emotional stimuli, which may be related to subjective emotional numbing. This study investigated two aspects of affective processing in 13 patients with DPD according to the DSM-IV criteria and healthy controls: the perception of emotional facial expressions (anger, disgust, fear, happiness, sadness, and surprise) and memory for emotional stimuli. Results revealed a specific lack of sensitivity to facial expression of anger in patients, but normal enhancement of memory for peripheral aspects of arousing emotional material. The results are consistent with altered processing of threat-related stimuli but intact consolidation processes, at least when the stimuli involved are potently arousing.

Attributions, appraisals and attention for symptoms in depersonalisation disorder.

A cognitive-behavioural model of depersonalisation disorder (DPD) suggests that catastrophic attributions and appraisals, and increased attention to symptoms, play important roles in the development and maintenance of the disorder. Empirical testing of this model was investigated in three groups: 25 patients with DPD, 21 patients with anxiety (obsessive-compulsive or panic disorder), and 22 psychiatrically healthy participants. Task 1 examined attributions for ambiguous symptoms. Task 2 used a questionnaire to compare the groups on the content, frequency, and conviction in appraisals when participants worried about their health. Task 3 employed four experimental manipulations designed to either increase, or decrease, attention to catastrophic appraisals and/or symptoms of DPD. Results indicate that the DPD group make less normalising attributions for symptoms (Task 1) and have more catastrophic appraisals (Task 2) than those in the Healthy Control group. The DPD and Anxiety groups were similar in their patterns of appraisals and attributions. In Task 3, the DPD group showed a perceived reduction in DPD severity when their attention was focussed on cognitively demanding tasks, whereas the other two groups showed an increase. The findings are consistent with the hypothesis that these cognitive processes play an important role in the development and maintenance of DPD.

The long-term effectiveness of cognitive behavior therapy for psychosis within a routine psychological therapies service

Randomised controlled trials (RCTs) have shown the efficacy of CBTp, however, few studies have considered its long-term effectiveness in routine services. This study reports the outcomes of clients seen in a psychological therapies clinic, set up following positive results obtained from an RCT (Peters et al., 2010). The aims were to evaluate the effectiveness of CBTp, using data from the service’s routine assessments for consecutive referrals over a 12 years period, and assess whether gains were maintained at a 6+ months’ follow-up. Of the 476 consenting referrals, all clients (N = 358) who received ≥5 therapy sessions were offered an assessment at four time points (baseline, pre-, mid-, and end of therapy) on measures assessing current psychosis symptoms, emotional problems, general well-being and life satisfaction. A sub-set (N = 113) was assessed at a median of 12 months after finishing therapy. Following the waiting list (median of 3 months) clients received individualized, formulation-based CBTp for a median number of 19 sessions from 121 therapists with a range of experience receiving regular supervision. Clients showed no meaningful change on any measure while on the waiting list (Cohen’s d <= 0.23). In contrast, highly significant improvements following therapy, all of which were significantly greater than changes during the waiting list, were found on all domains assessed (Cohen’s d: 0.44–0.75). All gains were maintained at follow-up (Cohen’s d: 0.29–0.82), with little change between end of therapy and follow-up (Cohen’s d <= 0.18). Drop-out rate from therapy was low (13%). These results demonstrate the positive and potentially enduring impact of psychological therapy on a range of meaningful outcomes for clients with psychosis. The follow-up assessments were conducted on only a sub-set, which may not generalize to the full sample. Nevertheless this study is the largest of its kind in psychosis, and has important implications for the practice of CBTp in clinical services.

Mental health practitioners' reflections on psychological work in Uganda: exploring perspectives from different professions

The Butabika-East London Link collaborated with Ugandan mental health services to train mental health professionals (psychiatric clinical officers, ‘PCOs’, and clinical psychologists and psychiatrists, ‘Core Group’) in psychological therapies. The aims of this research were to investigate how professionals were applying and adapting psychological therapies to the Ugandan setting and to gain ideas to inform future training. Focus groups were used to explore the PCOs (N = 13) and Core Groups (N = 8) thoughts. Recordings were transcribed and thematically analysed. Themes identified were: issues affecting psychological therapy provision; cultural adaptations; voices of service users; and training. Different professional groups share similar concerns about implementing psychological therapies in a country where psychological services are just emerging. Future directions are suggested.