CBT for Depersonalization/Derealization

I haven't seen many discussions of depersonalization from a CBT perspective even though it is encountered fairly frequently in clinical practice. My experience has been that it usually is fairly easy to understand in CBT terms and often responds quite well to CBT along the lines of Carl's suggestions.

It is important to note that the experience of depersonalization (and related experiences such as derealization, micropsia/macropsia, out-of-body experiences, etc.) is a fairly common experience which doesn't necessarily have anything to do with psychopathology. According to DSM-IV "At some time in their lives, approximately half of all adults may have experienced a single brief episode of depersonalization, usually precipitated by severe stress. A transient experience of depersonalization develops in nearly one-third of individuals exposed to life-threatening danger and in close to 40% of patients hospitalized for mental disorders." It also notes that "voluntarily induced experiences of depersonalization or derealization form part of meditative and trance practices that are present in many religions and cultures..." The experience of depersonalization of derealization is part of the normal range of human experience.

How can we understand the experience or depersonalization in CBT terms? My understanding (which was initially based on The Psychology of Anamolous Experience by Graham Reed) is that depersonalization is usually a side-effect of narrowly-focused attention. It can occur when an individual chooses to intentionally narrow their focus of attention (as in a number of forms of meditation) or when the focus of attention unintentionally becomes narrowly-focused due to focusing on feared stimuli, self-consiousness, a traumatic experience, etc. A simple way to induce the experience of depersonalization, if you wish to do so, is to locate a convenient mirror and stare fixedly into your own eyes for a few minutes. If all that happens is that the individual's attention becomes narrowly focused for a few minutes, the result is a brief experience of depersonalization. This is a common experience which is transitory, harmless, and has nothing to do with psychopathology.

However, most people who have this experience do not know that it is a common, harmless experience. In fact, many people interpret it as a sign that they are "crazy." This, of course, scares the individual and increases their tendency to focus their attention narrowly on their subjective experience. The more they focus their attention on their subjective experience and the more they are vigilant for signs of "craziness", the more likely they are to experience additional episodes of depersonalization. These subsequent episodes scare them even more ("OH MY GOD, IT'S HAPPENING AGAIN!"), this maintains their self-focused attention, which contributes to additional episodes of depersonalization, and this cycle easily becomes self-perpetuating. When episodes of depersonalization are persistent or recurrent, causes marked distress or impairment, but the individual maintains intact reality testing, DSM labels this Depersonalization Disorder.

We can approach treatment pretty much the way we would approach the treatment of a person with Panic Disorder who fears that their panic attacks are a sign that they are going crazy. First, we do a good evaluation and watch out for drug abuse, psychosis, neurological problems. Then, after establishing a good, collaborative therapeutic relationship, we need to identify the individual's fears/beliefs/interpretations of their episodes of depersonalization and address the dysfunctional thoughts we encounter. Usually this includes educating them about depersonalization and challenging their conviction that they are "crazy" or are"going crazy." In mild cases, education and reassurance are sometimes sufficient to allay their fears and the episodes of depersonalization fade away. However, cognitive interventions alone are usually not sufficient (as is the case with most anxiety disorders). It generally is necessary to follow the cognitive interventions by some form of in-vivo exposure. One option is to intentionally face situations where depersonalization occurs and to tolerate it rather than avoiding it or trying to escape from it. Another option is for the individual to intentionally induce depersonalization, perhaps by staring into their own eyes in a mirror as described above, and to tolerate the experience rather than trying to avoid or escape it.

My experience has been that for individuals with mild to moderate depersonalization, it may be possible to alleviate it with a session or two of intervention. With full-blown Depersonalization Disorder it can easily take quite a bit longer. I recently finished working with a young man who had both Panic Disorder and Depersonalization Disorder. After six sessions of intervention (and a number of crisis phone calls) his panic attacks had stopped and his episodes of depersonalization had been reduced by about 50% in both frequency and intensity. However, his fear of depersonalization and of panic were quite persistent. It took perhaps six months of weekly treatment until he was ready to terminate treatment. About a year later he had a partial relapse and about 10 weeks of additional treatment was needed (focusing primarily on his fear of "losing control"). Treatment was concluded successfully and I expect him to do well, but only time will tell.

Replies:

Clients' reaction to this view of Depersonalization/Derealization , by Jim Pretzer, 06/24/02

| Behavior OnLine Home Page | Disclaimer |

Copyright © 1996-2004 Behavior OnLine, Inc. All rights reserved.