Montana Mental Health Bulletin

Disorder Depersonalization

Dissociation is defined as a disruption in the usually integrated functions of consciousness, memory, identity or perceptions. Depersonalization is a particular type of dissociation involving disrupted integration of self-perceptions. Individuals experiencing depersonalization feel estranged, detached or disconnected.

Common descriptions of depersonalization experiences

• Watching yourself from a distance– like looking at a movie
• Out-of-body experiences
• A sense of just going through the motions
• One part acting/participating while the other part is observing
• Feeling like you’re in a dream or a fog
• Looking in the mirror and feeling detached from your image, speech or physical movements
• Feeling detached from your emotions - numbed or blunted

Short-lived experiences of depersonalization are common in the general population. Transient depersonalization is also common under severe or life-threatening stress. However, when depersonalization becomes persistent or recurrent and when it is associated with significant distress or impairment, depersonalization disorder (DPD) may be present. The prevalence of DPD in the general population is not known, but it is probably more common than its usual label of “rare” implies.

The average age of onset for DPD is around 16, although onset can occur in the 20s, 30s or even 40s. The disorder affects an equal number of men and women. Onset can happen so early that the individual has no clear memory of when it started – or it may begin with limited episodes and gradually become more pronounced. When onset is acute, the individual may recall the exact moment, setting, and circumstances of the first depersonalizing experience. An acute episode may occur after prolonged stress, a traumatic event or with the onset of another mental condition such as panic disorder or depression. Depersonalization episodes can also be brought on by acute marijuana, ecstasy or ketamine intoxication. When Depersonalization Disorder is present, the sense of estrangement continues after the stress or trauma is resolved, or after the drugs are out of the system.

DPD is episodic in about one-third of individuals, and each episode may last hours, days, weeks, or months at a time. For about 50 percent of those afflicted, it is always present in varying degrees of intensity. Many sufferers find the robotic, detached state analogous to walking dead – never feeling truly alive or real. Cognitive complaints are common. There is a decline in ability to focus on tasks, especially complex ones: increased forgetfulness in daily life and difficulty in vividly evoking memories.

Occupational impairment results in loss of work or working below capacity. Interpersonal relationships suffer from the intense sense of emotional disconnection from others.

The more severe Dissociative Identity Disorder (DID) is associated with traumatic stress or peri-traumatic dissociation, or dissociation surrounding the time of trauma. When compared with normal control subjects, DPD subjects had suffered significantly more childhood trauma and abuse. The spectrum of severity of dissociative disorders is represented at the milder end by DPD, which is characterized by chronic and moderate early abuse. More severe dissociative disorders, including DID, are marked by extreme early abuse. Common disorders often found in a co-morbid capacity with DPD are borderline, avoidant, and obsessive-compulsive disorders.

Treatment
Research on treatment is limited and no medical treatment guide lines exist. New classes of medications currently in development may hold promise for the treatment of DPD, but it does not appear that any of the medications currently available have potent anti-dissociative effects. A variety of psychotherapeutic techniques are helpful in treating DPD, particularly among patients who have not suffered from chronic DPD. Trauma-focused therapy and cognitive-behaviors techniques specifically tailored to DPD challenge negative automatic thoughts and encourage sufferers to re-experience emotions, to refocus their attention and block depersonalization while focusing on immediate experience. Journaling helps promote awareness of fluctuations in the intensity of symptoms.

Source: Sierra, M., Berrios, B.E. The Cambridge Depersonalization Scale: A New Instrument for the Measurement of Depersonalization, Psychiatry Research, 93: 153-164 (2000)

Gratefully adapted from an article by Dr. Daphne Simeon that appeared in Paradigm, Spring 2003, Dr. Simeon is an Associate Professor of Psychiatry at Mount Sinai School of Medicine in New York City, and holds degrees in biology, animal behavior ,and medicine. She is board-certified in psychiatry and has done extensive research in dissociation and self-injury.

Greetings from the MMHA President:

There’s a lot of news as MMHA continues to move in New Directions to advocate and educate for mental health. Executive Director, Charlie McCarthy, recently resigned to take a position with the Montana Advocacy Program (MAP). His advocacy talents will be put to good use there and we wish him the very best of luck as he moves forward.

We’re busy right now getting ready for two upcoming conferences. Bipolar Disorder: Navigating the Highs and Lows will be held September 26 at the Billings Sheraton. The second will be December 5 and 6 in Missoula, and will cover New Directions in Medication. Both will provide excellent opportunities to improve your knowledge in the field, and we encourage you to attend.

Because we’re headed in New Directions, we’ve also been working hard to communicate with existing and potential members. We are in the process of conducting a membership drive. The new brochure was designed with the assistance of development consultants, Dorothy Bradshaw and Sherrie Downing, who were hired last fall to help us focus our efforts to improve advocacy for mental health. The brochure is beautiful – thanks to the design skills of board member Joan Trost and the thoughtful input of board member Andrea Kenney. Our editor, Joan Trost, has been working with the development consultants since last fall to polish the new look of the newsletter. We continue to work with Public Policy and Children’s committees to fight for the needs of people with mental illness.

It’s important to hear what you have to say, so we’ve begun visiting affiliates this year. Past Executive Director, Charlie McCarthy, and I recently visited Big Timber/Sweet Grass. We also went up to visit Kalispell upon the invitation of Boyd Roth, an MMHA Board Member from that area. Finally, we visited the Sheridan/Daniels County Affiliates and held our annual board meeting there. In each case, we’ve had the opportunity to visit with many of you and to hear about your concerns and interests.

We’re always interested in what you have to say, so please feel free to give us your input! We appreciate ideas for conferences and articles.

In closing, I’d like to thank all of our members for their support and to the wonderfully active MMHA Board of Directors for all of their hard work. Together we really can make a difference.

Sincerely,

Cindy Dolan
MMHA President

Understanding Obsessive/Compulsive Disorder

Submitted by Mark Johnston, MD

A Day in the Life of Sally
After Sally complained of feeling discouraged and anxious over her inability to keep up with daily responsibilities, her primary care physician suggested she go for an evaluation of depression. Sally made the appointment and went to the psychiatrist’s office with apprehension. When the psychiatrist asked about her problems with time, Sally reluctantly admitted to a pattern of excessive cleaning. She would wash her countertops 6–8 times a day, even when they hadn’t been used. She seemed to understand that this activity was not necessary, but felt anxious if she didn’t clean. When Sally left her home to go shopping, she needed to check and double-check that the front door was locked. At times she would pull back in after leaving the driveway to recheck the lock that she had checked moments before. Her trips were often inefficient because she needed to follow tire marks diverging from the road for fear someone had run off the road.

OCD
Sally isn’t a real person, but this case history demonstrates a composite of symptoms experienced by individuals dealing with Obsessive-Compulsive Disorder (OCD). OCD is an anxiety disorder associated with repetitive thoughts and behaviors. Obsessions and compulsions range in severity, but can cause major disruptions in an individual’s ability to function socially, at school or in the work environment. Originally thought to be a relatively uncommon condition, in reality, OCD is one of the more common psychiatric disorders, affecting approximately 2 percent of the population. OCD often goes unrecognized because many individuals keep their repetitive thoughts and compulsive behaviors hidden from others and do not seek treatment.

Although most people experience repetitive worries or ruminations, the person with OCD has excessive fears that impact day-to-day functioning. Some may check their door locks 10 times before leaving the house. Because of fear of germs or contamination, others may wash so frequently that their hands crack and bleed. A person with OCD usually has both obsessions and compulsions, although some may exhibit just one or the other. The particular obsessional thoughts or compulsive behaviors may vary greatly from one individual to the next.

Obsessions
Obsessions are ideas, impulses, or images that occur again and again and seem uncontrollable. The individual experiences these ideas as intrusive and upsetting. Most commonly, the person understands that these fears and repetitive thoughts are excessive or unrealistic. Common obsessions include fear of contamination or imagining impulsively hurting a loved one.

Compulsions
Compulsions are repetitive activities performed to ease anxiety associated with obsessions. The two most common compulsions are washing and checking. Some people have highly regimented rituals while others have compulsive behaviors that may vary over time. Compulsive behaviors in OCD do not provide direct pleasure (such as the use of drugs or alcohol), but are performed to decrease anxiety.

Obsessions and compulsions have traditionally been distinguished from delusions by virtue of insight into the unreasonableness of the idea or behavior. Individuals with OCD do, however, demonstrate a range of insight with regard to the unrealistic nature of their obsessions and compulsions.

Other Features of OCD
OCD symptoms often are first experienced in adolescence or early adulthood but recent research suggests that the condition often occurs earlier. Approximately one-third of OCD begins in childhood. Unlike adults, children may not see their OCD behavior as unusual. OCD affects men and women in equal numbers. OCD is usually a chronic condition lasting over years but may vary in intensity of symptoms. There can be a great difference in severity between individuals as well. Some people experience only mild features while others may be essentially incapacitated by symptoms. There is now a clear association of OCD with variations in the neurotransmitter function in serotonin and dopamine systems in the brain. It is likely that the interplay of biological, cognitive and environmental factors is important in the development of the condition.

Treatment
FDA-approved medications shown to be effective for OCD include Anafranil (an older tricyclic family antidepressant) and several of the newer serotonin re-uptake inhibitors (SSRIs) including Prozac, Luvox, Paxil, and Zoloft. Individuals respond differently to the various prescriptions, and occasionally Anafranil may be combined with an SSRI. Since the response for OCD is generally slower than for depression, perceived improvement may take weeks, with the full effect 8-12 weeks after initiation. Effective dosage levels tend to be somewhat higher than those used for depression.

Traditional insight-oriented psychotherapy is not usually effective for OCD. Cognitive-behavioral therapy involving exposure and response prevention techniques can, however, be very helpful. Treatment is a step-by-step process with patients learning how to tolerate anxiety and control compulsive urges.

Although current therapies do not usually produce a complete resolution of symptoms, many people experience substantial improvement and much more comfortable and functional in their day-to-day lives. Current research by the National Institute for Mental Health (NIMH) and other academic centers is ongoing and further improvements in effective treatment are likely in the years to come.

Books about OCD

Anxiety and its Treatment: Help is Available, by John Griest, MD

The Boy Who Couldn’t Stop Washing, By Judith L. Raoport Getting Control, by Lee Baer, PhD

OCD: a Survival Guide for Family and Friends, by Roy C. Over and Over Again, by Fugen Neziroglu, PhD and Jose Yaryuara- Tobias, MD

Stop Obsessing! by Edna Foa, PhD and Reid Wilson, PHD

When Once is Not Enough, by Gail Steketee, PhD

Source: Common Obsessive, Intrusive Thoughts Compulsive Ritualistic Behaviors and Other Clues to OCD, Unlocking the Captive Mind Together, When Someone You Know Has Obsessive Compulsive Disorder, Solvay Phamaceuticals, The Upjohn Company 1995.

Dr. Mark Johnston is the Administrator and Senior Medical Director of Pathways Treatment Center in Kalispell. A frequent lecturer, Dr. Johnston enjoys teaching as well as working with patients. Married to Joan with one daughter Katie, Dr. Johnston is an avid musician with Glacier Orchestra, a fly fisherman, and an artist. He can be seen driving a classic 1964 Corvette on the occasional sunny day in Kalispell.

Association Updates

New board members were nominated at the 2003 Montana Mental Health Association Annual Meeting held in Glasgow, Montana in June. A warm welcome to:

• Rich McRae, Helena
• Michelle Helms-Raper, Great Falls
• Julie Maggiolo, Warm Springs
• Dawn Smith, Great Falls
• Linda Wetzel, Billings

The Charles Averill Volunteer of the Year Award for an outstanding individual who has furthered the cause of mental health in Montana was awarded to Joan Stockton of Grass Range. The Exemplary Service Award went to Joan Trost of Great Falls.

Fall Conference: Bipolar Disorder, Navigating the Highs and Lows will be September 26, 2003 at the Billings Sheraton Hotel. Dr. Mark Viner, Clinical Assistant Professor, Department of Psychiatry and Behavioral Health, University of Nevada will present, The Role of Atypical Antipsychotics in Mood Disorders. Dr. David Yelvington, psychiatrist at Behavioral Health at Deaconess Billings, will present, Bipolar Disorder: Stabilization for the Long-Term.

Diagnostic Criteria for Dissociative Identity Disorder (DSM-IV: 300.14)

• The presence of two or more distinct identities or personality states.
• At least two of these identities or personality states recurrently take control of the person’s behavior.
• Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
• The disturbances not due to the direct physiological effects of a substance. Note: in children, the symptoms are not attributable to imaginary playmates or other fantasy play.

Diagnostic Criteria for Depersonalization Disorder (DSM-IV: 300.6)

• Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one’s mental processes or body.
• During the depersonalization experience, reality testing remains intact.
• The depersonalization causes clinical significant distress or impairment in social, occupational, or other important areas of functioning. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another dissociative disorder and is not due to the direct physiological effects of substance or general medical condition.

Upcoming Calendar of Events

April 1-2, 2003
Cognitive Therapy Unplugged, Essential Therapist Skills for All CT Applications: presenter Christine Padesky, PhD, Hampton Inn, Great Falls, MT. Sponsored by MHA Great Falls. For more information, go to: www.padesky.com

September 26, 2003
Bipolar Disorder: Ups and Downs: Billings Sheridan, Billings, MT. Sponsored by MMHA. For more information, call 1-800-823-MHAM or E-mail, mham@in-tch.com

October 8-10, 2003
The Montana State Conference on Mental Illness: Billings Sheridan, For more information, call Sandy Mihelish at 458-9738

November 6-7, 2003
Native American Mental Health Conference; Focus on Youth: For more information call, For The Children Coalition at (406) 452-0155

December 4-5, 2003
New Directions in Psychotropic Medications: Double Tree/ Edgewater Hotel, Missoula, MT. For more information, call 1-800-823-MHAM or E-mail, mham@in-tch.com. Coming Next Year

News Briefs

People With Schizophrenia Face Significant Barriers to Treatment
A new NMHA national survey reveals three core barriers to treatment. Consumers, their family members, and friends identified stigma as the number one barrier to effective care. Second, a lack of adequate insurance coverage followed by restricted access to appropriate services. Through the survey, “Barriers to Recovery,” NMHA revealed that about 58 percent of people with schizophrenia and 47 percent of caregivers believe that successful treatments for schizophrenia exist - a belief shared by less than one-third of the general public. These findings highlight the need for public education to further break down the barriers to treatment and services for people who have schizophrenia.

Teen Depression: Hello! My name is Elizabeth and I am a freshman at the University of Arizona. Throughout high school, I experienced symptoms of depression and anxiety. I never felt that there was a book that “spoke to me” as I was coping with my mental health. I am currently in the process of writing a book for teens with mental illnesses. If you are a teen and would like to share your recovery story in my book, please contact me at (480) 518-1128.
Elizabeth Drucker

The President’s New Freedom Commission on Mental Health released its report on recommendations to improve America’s broken mental health system. Together the Bazelon Center for Mental Health Law, NAMI, National Association of State Mental Health Program Directors, and National Mental Health Association commend the Commission for its work. Our organizations call on President Bush and Congress to take the next bold steps needed to realize the Commission’s recommendations and make mental health a national priority.

The Bazelon Center for Mental Health Law is the leading national legal advocate for people with mental illnesses or mental retardation. Through precedent-setting litigation and in the public policy arena, the Bazelon Center works to advance and preserve the rights of people with mental illnesses and developmental disabilities. For more information, visit www.bazelon.org.