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elliot m

on 10 December 2013

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Transcript of Depersonalization

Treatment Plan

Previous Techniques
based on the idea of misinterpretation of transient depersonalization as indicating severe mental illness; vicious cycle of heightened sensitivity and chronicity
so far, seems most effective in patients with comorbid anxiety and/or depression*
for some minority of a group with anxiety/depression may reduce depersonalization symptoms, but not largely effective for DPD (HPA/cortisol differences from other disorders)
Interoceptive Exposure
used when patients experience high anxiety sensitivity to the experience of panic and subsequently depersonalize
There are no treatments that currently exist that have been shown to target and relieve depersonalization in most patients, and the disorder typically lasts for years or decades (Simeon, 2003)
Why might these treatments not work?
neuroimaging studies of DPD and dissociation
show high cognitive control/frontal lobe activation + less bottom-up emotional/amygdala responses to emotional content compared to controls; impaired emotional processing, body schema abnormalities*
(basis for new dissociative subtype of PTSD in DSM 5!)
respond earlier to startling noise, reduced autonomic response to unpleasant stimuli (selective inhibitory mechanism)**
CBT seeks to improve cognitive control and cognitive awareness- DPD patients are hyper aware of their thought processes (this is one of the symptoms of the disorder)
Treatment Overview
This treatment seeks to attack depersonalization via (1) sensory awareness/input (2) bodily awareness (3) emotion awareness
module length depends on patient's needs; meet 1x/wk
draws on autism and BPD treatments
building trust with the therapist is essential
remember: high threat awareness, selectively inhibit emotions
comfortable social interactions relieve symptoms (Simeon, 2003)
don't show discomfort with emotions- they will be highly attuned
several medical conditions trigger DPD symptoms (and depersonalization has shown to be triggered by inducing these medical conditions); keep in mind medical rule outs
if the patient is highly anxious or severely depressed, tackle this first (CBT, interoceptive exposure)
at all times, tackle any cognitive distortions and reassure the patient that they can be candid and their DPD symptoms do not mean they are severely mentally ill
"You have a body, your mind is a part of your body, you can affect your mind by affecting your body" (we are getting to the emotions through the body)
"the subjective experience of unreality and detachment from the self"*
reality testing remains intact (not delusional, not hallucinating- "i feel as if")
feeling "trapped in a fog"
feeling robotic, moving automatically through the world but not engaging with it, "on auto pilot"
places and people that should feel familiar do not
feeling that the outside world is distant and strange
disconnection from all emotion (positive and negative)

present often as a symptom, but chronicity= Depersonalization Disorder (DPD)
often highly functional, low impairment (can be very distressing)
*Simeon, D., Knutelska, M., Nelson, D. et al. (2003). Feeling unreal: a depersonalization disorder update of 117 cases.
Journal of Clincal Psychiatry, 64
(9), 990–997.
*Hunter, EC. (2005). CBT for Depersonalization Disorder: An Open Study. Behaviour Research and Therapy, 43, 1121-30.
*Frewen, P., Lanius, R. (2006). Toward a Psychobiology of Posttraumatic Self-Dysregulation. Annals of the New York Academy of Sciences, 1071, 110-124.
**Sierra et.al. (2002). Autonomic Response in Depersonalization Disorder.
Archives of General Psychiatry, 59
(9), 833-838.
Sensory Regulation
there are several studies that show sensory processing abnormalities in DPD
DPD patients seek strong physical/emotional input,
positive or negative
(i.e. putting their head in a bucket of ice water) for temporary relief of depersonalization symptoms
the goal is "
sensory diet" for hypo/hypersensitivity, proprioception (the sense of your body in space)

Step 1
How "aware" of your body do you generally feel? Have you tried anything to "come back" from feeling disconnected from your body? How effective was it?
Step 2
Make a list of exercises tailored to the client. Swimming, swinging, and rocking are tested methods for engaging proprioception. Joint compression (the Wilbarger technique) with either exercises or an occupational therapist, wrist/ankle weights, massage, hot bath, keeping some interesting textures with you, anything to increase tactile awareness.
at every point, apply the mindfulness techniques you have learned
Step 3
Make an action plan for which methods will be used when.
Step 4
Record your experiences (incl. mindfulness) and report back. How aware of your body did you feel? Did you notice any physical/emotional discomfort? How did you respond?

before anything else, you must start with grounding
depersonalization patients may feel they do not need to ground; unlike BPD they have no problem regulating their emotions
, the mechanism that (likely at this point automatically/unconsciously) regulates their emotions is so effective that they probably aren't even present during therapy
don't shame how they may be regulating their emotions; tell them how effective it is and that you are looking for a way to "turn their brain off/thoughts off," which they will likely understand
if leading them through grounding makes them a little uncomfortable, that's probably good- depersonalization is very comfortable because you feel very little! your goal is to make them feel even if it's horrible
don't do anything stressful or unexpected; always let them choose what works best for them, have them actively involved
Step 1
What are you feeling? How strong are these emotions/bodily sensations?
Step 2
Create a list of grounding exercises with the client. Examples include touching surroundings or a small grounding object (this is my body/home/safe), breathing exercises, being aware of the weight of your body, having an object or mental image that gives you a sense of safety/security, paying attention to tastes or pleasant noises, etc; try to stay away from overly strong sensations/extremes*
Step 3
Try at least one grounding technique now.
Step 4
What are you feeling? How strongly? Has anything changed?
Step 5
Homework: Whenever you feel depersonalized, use one of your grounding techniques. Rate their effectiveness. If they don't work, try for a bit longer. It's ok to feel anxious or distressed. *encourage them to call in if they feel very distressed at any point

Radical Acceptance (adapted)
Radical acceptance is a concept often used with trauma and BPD patients; taoist/somewhat buddhist origins
Introduce radical acceptance in the wake of successfully establishing grounding skills. Practice in office until comfortable, then assign as homework, increasing number of times per week, then per day

When emotions do arise:
. Use one of your grounding techniques.
. What are you feeling?
. Your emotions are normal and human.
Sit with it
. Don't try to control your anger/sadness/happiness. Don't use words to judge, categorize, or understand emotions. Feel whatever you are feeling. Feeling horrible or elated is ok.
. Suffering and joy are a part of existence. They will come and go. Everything ends at some point. (adapt flowery language as need be) Don't get mired in the emotions of the moment to the point of distress, but there's no need to get rid of them entirely* either.
. Do something relaxing/fun/calming to take care of yourself or reward yourself. Make sure you feel present and secure. If you notice you are depersonalized, remember there's no need to be anxious; ground yourself calmly and gently.

Mindfulness/Body Awareness
Mindfulness is foundational for some of the later techniques
It involves constantly reminding oneself to remain in the present and notice one's surroundings and self
Practice with the client. Make it fun and interesting. For instance, you can use candy, a complicated object, or an outdoor setting.

Rate body/emotion awareness before and after:
1) Mindfulness:
What are you feeling/tasting/smelling/hearing/etc? Describe it in detail. Don't try to change or think critically about these feelings, just notice them and describe them. Be mindful, not automatic.
2) Body Scanning:
What are you feeling in your hands/feet/etc? Each finger, each knuckle, etc.
3) Relaxation:
(consider using a tape)- mindfully relax every muscle in your body, feeling the tension and release
End Goals
Reducing distress with education and tools to cope and reduce symptoms
Replacing depersonalization with effective and less harmful responses
A sense of self-efficacy, control, and hope
Reducing the frequency and severity of symptoms, potentially no longer meeting criteria
Integrated body/emotion awareness
Balanced sensory diet
Decreased avoidance, increased emotional presence (life enjoyment, grief*, etc), improvement in relationships
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