# Treatment Theories from Research, some ideas to help you!



## David Kozin (Jan 11, 2005)

This is how I get myself in trouble. Here is an article purchased from donations from people like you. I do not have the resources to write a review legally, so I am presenting a portion of the text for academic reasons. I hope this is helpful.

_*All my love and support for your community

- David*:_

FROM: Depersonalisation disorder: a cognitive?behavioural
conceptualisation, E.C.M. Hunter ∗, M.L. Phillips, T. Chalder, M. Sierra, A.S. David,  2003 Elsevier Ltd. All rights reserved.

*Abstract*
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.

A SECTION FOR DRUG-INDUCED DISORDERS
"Other common precipitants for DP and DR include acute intoxication or withdrawal from alcohol and/or a variety of drugs, especially ?ecstasy? (McGuire, Cope, & Fahy, 1994), marijuana (Moran, 1986) and hallucinogens such as LSD (Waltzner, 1972). These symptoms may be prolonged if usage took place during a time of stress alongside co-morbid psychiatric diagnoses (Keshaven & Lishman, 1986; Szymanski, 1981) even with only infrequent use (Simeon et al., 1997). Depression is also a common precipitating factor, with Mayer-Gross (1935) reporting 50%
of sufferers describing the onset of their depersonalisation during the course of an episode of depression and Ackner (1954) and Sedman (1972) defining concepts of a ?depressive depersonalisation? syndrome. In these cases it is possible that the main focus of concern for the sufferer is
the sense of detachment and emotional numbing which result from the depression. Finally, in a minority of cases no precipitating factor can be elicited (Simeon & Hollander, 1993). This may be due to the onset of symptoms occurring following, rather than during, a period of extreme
stress (Shorvon et al., 1946) or because of lack of disclosure (Roth, 1960)."

*3. Implications of the model for treatment*

The cognitive?behavioural model of DPD described above, based on models of anxiety disorders,provides a framework for the construction of an individual conceptualisation of those factors that are likely to have predisposed and precipitated the presenting problem, and which
continue to perpetuate the symptoms. Each of these individual factors should be addressed in therapy, with initial emphasis placed on effecting change on those factors deemed to be maintaining the disorder and later focus on predisposing and precipitating factors to prevent relapse.
Below we outline some interventions that are likely to be useful in the treatment of DPD.

*Psycho-education and normalising*
Engagement of the patient through the shared understanding of a clear rationale for their symptoms and treatment is a cornerstone of effective CBT. This is particularly emphasised with DPD sufferers who have been found to have an average time of 7?10 years before being given their
correct diagnosis of DPD (Steinberg, Cicchetti, Buchanan, Hall, & Rounsaville, 1993) or around 12 years in a UK clinic (Baker et al., 2003; Phillips, Sierra, Hunter, Lambert, Medford, Senior et al., 2001) and are likely to have had conflicting information about their problems during this
time. Psycho-education and normalising of their symptoms therefore can form an important part of treatment. Many patients report the enormous sense of relief that comes from being told that their often bewildering array of symptoms form a well-defined syndrome. Information regarding
how commonly the transient symptoms of DP/DR are experienced in the population, particularly during periods of stress or threat, is reassuring to the sufferer. If the patient has a history of panic, the high proportion of panic sufferers who report transient symptoms of DP/DR during panic
states can be presented. The ?normalising? description of the role of DPD as a protective method for dealing with these overwhelming feelings by effectively distancing oneself from them finds favour with most sufferers. If during assessment the patient has identified anxiety producing situations
as increasing their current symptomatology, this can be used as additional evidence to support the links with anxiety.

*Diary keeping*
This can be useful in highlighting to the patient the variability of their symptoms, since many sufferers have a tendency to view their DPD as unremitting. It will also emphasise that changes to their behaviour and their thoughts can have an impact on their DPD and increases the belief
that their symptoms are controllable and not necessarily a sign of permanent neurological damage, as well as introducing the concept of ?homework?. For the therapist, the diary may also highlight
symptom-led behaviour by indicating a ?boom and bust? pattern, with extremes of activity and inactivity similar to that frequently seen in chronic pain and chronic fatigue syndrome where the person adjusts their behaviour according to the severity of their symptoms (Deale, Chalder,
Marks, & Wessely, 1997). If this is the case, an average level of activity can be calculated, and achievable targets agreed upon with the patient. The therapist may also want to increase activity levels if the diary clearly indicates an overall low level of activity that may be contributing to lowered mood and motivation with increased introspection and symptom monitoring.
*
Reducing avoidance*
Behavioural interventions are likely to include reducing avoidance through graded exposure. Typical situations that are avoided are those that result in increased anxiety, such as socialising, crowded public places and driving due to fear that the unreality of the situation will lead to accidents. A review of techniques to overcome social anxiety will be valuable in the majority of cases, for example videotaping of social interactions may be useful for the sufferer to reassure them how little their symptoms are detectable to others. Some ?safety behaviours? might include maintaining a fixed expression, keeping very still, making minimal eye contact, trying to say the ?right thing?, which leaves the sufferer with the feeling that they are simply going through the motions of social interaction. Role playing with, and without, the use of safety behaviours will
allow the patient to see for themselves whether their safety behaviour serves to help or hinder their performance.

Refocusing and grounding techniques are used to combat a range of dissociative phenomena including DP/DR (Kennerley, 1996). Refocusing through the use of specific, predetermined, words, objects, images or self-statements can help the person increase their contact with reality,
orientate them to their immediate environment, and break the cycle of increasing self-focussed attention on their symptoms. However, these are likely to be useful strategies only when the DP/DR reported is intermittent so that the sufferer can intervene before symptoms worsen. However,
their continual usage in those with severe and relatively non-fluctuating symptoms would be likely to interfere with normal functioning and could develop into a maladaptive ?safety behaviour?. Sufferers reporting severe and chronic DP/DR symptoms may instead be helped by techniques
that reduce the degree of self-focussed attention or symptom focussing, since this has been found to worsen symptoms in social phobia (Clark & Wells, 1995), panic (Wells, 1990) and hypochondriasis (Salkovskis and Bass, 1997). Two such interventions are attention training(Wells, 1990; Wells, White, & Carter, 1997) and task concentration training (Bogels, Mullens & De Jong, 1997). In attention training, the patient enhances their ability to control their sustained attention, attention shifting and divided attention skills through a series of exercises. Similarly, in task concentration training, patients are encouraged to gain insight into the proportion of their attention which is focused on (1) internal stimuli; (2) external, irrelevant stimuli; or (3) external, task-related stimuli. Through a series of exercises the patient is trained to increase the degree of externally focussed, task-related, attention, initially in non-threatening situations and subsequently in threatening situations.

*Challenging catastrophic assumptions*
Cognitive interventions such as thought records (Beck, Rush, Shaw, & Emery, 1979) can be used to identify specific negative automatic thoughts which occur in anxiety producing situations, or when the symptoms of DPD increase. These negative cognitions can then be reality tested and more balanced thoughts offered as replacements. During assessment it is important to elicit as many of the feared consequences that the patient
may have imagined might occur as the worst outcome from their DPD (see Fig. 2). Once the therapeutic alliance is well-established and progress has been made with more behaviourally orientated interventions, these catastrophic misinterpretations can be gradually challenged through education, experimentation and evidence gathering. For example, if a patient fears that an increase in their DPD would result in them losing control, a detailed list of what this would entail should be constructed. The patient is then encouraged to test this hypothesis by carrying out behaviours that have previously increased the DPD severity to discover if their predictions are realised. If this in vivo experimentation cannot be conducted through difficulty in increasing symptoms or
patient reluctance to do so, the therapist and patient can instead examine the patient?s worst episodes to determine why the feared consequences were not realised. Obtaining belief ratings for each feared consequence at regular intervals through therapy will monitor the success of
these interventions. However, if challenging the catastrophic attributions does not effect change in symptomatology, this may be due to the sufferer having developed a repertoire of safety behaviours that they believe prevent the feared outcome. As in other cognitive behavioural treatments the setting up of behavioural experiments with clearly defined predictions where sufferers ?drop? their safety behaviours allows them to test the efficacy of these behaviours in preventing the feared catastrophe.
Finally, physiological interventions can also be incorporated in the treatment of patients with DPD, such as applied relaxation training (Ost, 1987) and education regarding the role of hyperventilation in anxiety and panic, with training in diaphragmatic breathing. However, over-reliance on relaxation techniques may exacerbate DP/DR symptoms in some cases by inducing an underaroused state (Fewtrell, 1984). Since many patients acknowledge fatigue as a trigger for worsening of the DPD, discussion on sleep hygiene, exercise and diet is worthy of inclusion. In our unit at the Institute of Psychiatry in London, an initial trial has been conducted into the efficacy of CBT with patients with primary DPD (manuscript in preparation). Eleven patients (nine men, mean age 41 years, mean duration of symptoms 18 years) completed a course of CBT that included the above interventions. A range of measures were administered at pre- and posttreatment, and at 6 months follow-up. Significant improvements in patient-defined measures of problem severity, standardised measures of general functioning and depersonalisation/derealisation severity were found at post-treatment and 6 months follow-up. These initial results suggest that a cognitive?behavioural approach to DPD may be effective, but further trials with larger sample sizes and more rigorous research methodology are needed.

------------------------
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## Guest (Jul 1, 2007)

Thanks a lot my friend


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## Guest (Jul 1, 2007)

Did you buy the article from http://www.sciencedirect.com ?


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## David Kozin (Jan 11, 2005)

Science direct is a great location. Other time I will go to the publisher, and when possible (for example, when I was working at the Science Library I downloaded a "few" articles for review).

- David


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## Dreamer (Aug 9, 2004)

This sounds like the book coming out at the end of July, at least in the UK, called:

*Overcoming Depersonalization and Feelings of Unreality

Anthony S. David, FRCP, FRCPsych, MD is Professor of Cognitive Neuropsychiatry at the Institute of Psychiatry and the GKT School of Medicine, London*

It is on amazon.co.uk and on a Danish site I believe, but it doesn't show up on the US amazon, or at Barnes & Noble.

Any Europeans, will you look for this book -- it is supposedly a coping book directed at DPers. Paperback. It says L9.99 which is $20.00?

Just realized I could look on the Canadian site, but shipping will probably be more than the book! I want the darned thing.

My thought, for me -- but I'm a long-timer -- is I wish I had had some form of intervention in my panic/anxiety as a child. Curious that this deals specifically w/DP/DR using CBT.

Perhaps the book is an extension of this research.

Please post if anyone sees this book!

Thanks

Oh, 256 Pages
Constable and Robinson Publishers
English
Due 26 July, 2007


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## Dreamer (Aug 9, 2004)

Not on the Canuck amazon site either. Dear Brits, help. I'd love to have it in my hands this moment, just out of curiousity.


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