Psychiatry & Psychotherapy Podcast - Depersonalization and Derealization

Episode Date: July 26, 2023

In this week's episode of the podcast, we are joined by registered mental health nurse, Paul Molyneux, to discuss depersonalization/derealization disorder and his personal experiences and recovery from the disorder.  By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

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research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today with Paul Molinew. He is a registered nurse in the UK, and he is going to be talking about his experience of depersonalization, derealization disorder, which he had for about two years. He has ridden up, you know, I get people that reach out to me, and I ask them, hey, write something up, and he put together this killer review on depersonalization, derealization that I have on my website, Psychiatrypodcast.com. He also has a kind of a nursing level coaching that he provides at www.w.

TheDP Guidancecenter.co.uk. And he is someone who has read the hardcore literature on this. He is summarized in our document. So today you're going to get a treat. We don't know as mental health professionals a lot about depersonization derealization. I don't remember one single grand rounds that I've ever heard on this. I've read some articles because of personal interest and I've treated that patients mostly coming off of marijuana who have this. I've had a number of patients who also suffer from like panic disorder or like

OCD who have this at times or I've had a couple of patients with psychosis who have had this sort of description of the dissociation, like a thing that they're describing where they do not feel like they themselves are real or the world around them is real. So depersonization, I do not feel real. Derealization, the world does not feel real. So welcome to the podcast, Paul. Hey, great to be here. Thank you for having me. I was thinking maybe we could start by reading that pretty pimping by Kurt Vile that from the lyrics. Yeah, it's a really, really amazing song. I think I read it on a Reddit forum about people who were listing songs about kind of

dissociation and this one kind of came up. It's an amazing song, sort of a real kind of piece of Americana. So it says, I woke up this morning, didn't recognize the man in the mirror. Then I laughed and I said, oh, silly me, that's just me. And I proceeded to brush some strangers' teeth, but they were mine. teeth and I was weightless just quivering like some leaf coming in the window of the restroom. So the whole song appears to be about this kind of person that doesn't recognize themselves, even when they look at themselves in a mirror, which is very evocative of that kind of depersonalization

experience. Yeah, then I proceeded to brush some stranger's teeth, but they were my teeth. And I was weightless. That weightlessness and the dissociation is very common. quivering, just quivering like some leaf come in the window of a restroom. It's like this kind of like weightless feeling, this disconnection from your body.

He's doing things to his body that he doesn't feel like her his own body. Yeah. I mean, I would love to get the background is why he wrote that song. Oh, yeah. Yeah, I mean, it must be something going on, maybe his experience, I suppose. Yeah, so let's just begin with,

how common it is for someone to have maybe a little bit of this, you know, like maybe not the full disorder, but just a little bit of an experience of depersonalization, derealization. It's actually probably more common than you may think. I mean, there was a study which I think was over in the U.S., which telephoned individuals up and asked them, have you had an experience of depersonalization de-realization last year. and around a quarter of people said that they did. So this is a far from rare, rare experience that people are having. And the lifetime prevalence, I mean, this is towards the higher end of studies around

kind of prevalence over the course of a lifetime. But they get to being as high as around 70%. So we may think this as being a very strange, a very unusual experience, but in fact it appears to be a relatively common experience that people have and we may place this perhaps on a spectrum like we may do other mental health symptoms where people have it just as part of their normal experience, a reaction to stress or fatigue or whatever

may have it kind of sporadically and then you have the kind of disordered end of the spectrum where people have this more kind of persistently and problematically but I suppose we can talk about this later but it's not necessarily a problematic experience it's not an inherently problematic experience yeah it's often associated with the fatigue the stress substance use

and what you're saying from these studies is that it's a common experience that someone might have this fleetingly for a couple hours for a day or two, that's fairly common. And okay, so maybe we could start with what is the diagnostic criteria for depersonalization, derealization.

You know, take us through the DSM-5 and where we are today with this, with the name. So, I mean, previously, the DSM-4 used to refer to it as depersonization disorder, but it's now referred to as depersonalization, derealization disorder in DSM-5, which I think better than kind of encapsulates what this disorder is.

De-personalization is this kind of subjective sense of feeling in some way kind of disconnected from oneself, which can manifest itself in several different ways. So, for example, people may feel disconnected from their reflection in the mirror, so they may not recognize themselves in the mirror, or it may feel as though it is somebody else looking back at them, or when they look down at their hands, it may feel like it might as well be kind of somebody else's hands

that they're looking down upon. People may feel in some way disconnected from their own emotions or thought, so they feel the emotion. They have the thoughts, but they might as well be kind of somebody else's thoughts or emotions. It's almost like they're kind of a passive observer to enter these experiences. movements may feel automated or like the movement of an automaton. People may feel this is something I definitely kind of resonated with my own experience of the disorders.

I would walk into a room that would be very familiar to me. So, for example, my bedroom that I grew up in at home and I'd visit my parents at home. And whilst I knew the room was my childhood bedroom, it didn't feel that way. it just felt completely felt disconnected and kind of numb towards it, no emotions towards that room. And people can have this experience of almost like an out-of-body experience where they may feel like they're watching themselves from outside themselves in some way. So this depersonalization is this subjective sense of feeling in some way detached from oneself.

Derealization, I think, is a little bit easier to explain. The de-realization is this kind of subjective sense of, feeling of somewhere disconnected from one's kind of surroundings. So reality may take on a kind of unreal, foggy, kind of lifeless or dreamlike quality to it, which can be kind of very disturbing for individuals. And so I mean, the primary criterion in the BSM-5 is that you must have

one or the other or both of these experiences deeper, personalization and de-realization in a kind of persistent and recurrent fashion. So it wouldn't be kind of an episode. It would need to be a persistent episode of this disorder or a recurrent episode of these experiences. Yeah. Yeah. So depersonalization, unreality, detachment, being an observer with respect to one's thoughts,

feelings, sensations, body, or actions, like these perceptual altercations, distorted sense of time, unreal or absent self, emotion or physical numbing, right? And then de-realization is the experiences of unreality or detachment with respect to the surroundings. So de-realization is like here, like, reality. It's like this detachment. I like how you said, it's like that numb or dreamlike or foggy or visually distorted. So when you had it, you had it for like two years. Yes.

Which of these did you have the most depersonization or de-realization, would you say? So for me, the primary, and the most distressing symptom was the sense that reality just felt, I felt like I was watching a movie of my life. So reality just felt like I was watching a film or that I was in a dream. And I felt as though almost like a pain of glass being placed in front of me and reality. It was a very, very strange sensation to experience. So my primary symptom was that. What I came along for the ride was this kind of depersonization.

And like I said, like I'd go into very, familiar rooms and I just feel completely detached from these rooms like I'd never been in them before for example my childhood bedroom and also I kind of feel very distant from my from my reflection when I looked at it in a mirror and my hands felt just as though it may be somebody else's hands and all kind of really really distressing symptoms to have or I found it extremely distressing and so you said it started with a panic attack at some point you had like a panic attack and then it kind of progressed into this yeah so i yeah i mean i guess um i suppose i was vulnerable to this disorder because for as long as i can remember

for whatever reason i've always had this kind of episodic experience of this feeling of reality so when i was a child if it was a very very hot day i'd have this experience of the realisation and it would come and then it would go, and it was unproblematic. Up until kind of sort of 2006, 2007, and I've experienced in panic attacks, and we obviously kind of know that these kind of dissociative experiences kind of come along for the ride when people have panic attacks, and I kind of got really latched onto this symptom, the specific symptom of a panic attack.

I then had a panic attack, and the realisation was, part of that and then after the panic subsided the de-realization kind of remained and kind of remained for the next kind of two two years oh wow and just just so we can kind of more understand this how old were you when this happened uh about uh 21 21 yeah 20 21 yeah was there um any substances associated with the initial panic attacks initial? No.

I mean, a lot of people for this disorder I think you've alluded to a new introduction will have a smoke of some weed or another drug

they will experience panic during that experience and the drug may bring on a dissociative kind of element to it and after the kind of weed is out the system or the drug is out the system

people will the depersonalization de-reliization will remain. So for some people, it can be substance use, which is their kind of vehicle towards this disorder for other people. It can be kind of panic. And for other people, it can kind of be other reasons that may or maybe more kind of insidious and just kind of it creeps upon people slowly. So ever since you can remember, you've, you've had dissociated episodes or dissociation episodes. Yes. And then how long would they last when you were a

were they like a couple minutes or? A couple of minutes, couple of minutes. I mean, maybe kind of half an hour, I'd guess. I mean, it's obviously interesting because I've recently had a conversation with an auntie of mine who's kind of in her 70s and she says that she also has these experiences as well. And I has had them for a very long time. So my suspicion here is that I have a, perhaps a genetic vulnerability to this. and then other factors later on in my life kind of led to this becoming a disorder.

Yeah. And then any like other medical things like migraines or seizures or anything like that? No, I mean, so it's kind of interesting you say that because it is true to say that these symptoms can be part of a physical illness or diagnosis. So one of the diagnostic criteria the DSM sets out is that these experiences should not be due to another physical, physiological kind of reason.

So for example, it's with temporal lobe epilepsy, people with migraine, people with head injuries like concussion, and kind of pose viral symptoms. So we see a lot of people with kind of COVID who described this kind of

foggy brain kind of sensation. So in making a diagnosis, you'd want to rule out those factors. Because if it's attributable to those factors, then you wouldn't make me a class here for the diagnosis. Yeah, I felt some of that for about a week or two after COVID. I just felt like I was like, yeah, like a walking zombie. You just did not feel myself, you know. And I know some people, I've seen a couple people who have that long COVID.

and they have that continued, you know, experience of like not feeling back to normal, not feeling themselves. Yeah. And therapy and different treatments, sometimes creative. One patient I had to start cold plunge, and that was what did it for her. She does it every morning for like five minutes. She goes in a river near her house. She lives in a cold area.

And that just kind of like does. something to her that gets her out of it. It's extremely interesting you say that I've got a colleague who had long COVID and she does the same thing and that's what helps her is she goes swimming in a very cold lake. Yeah, do it with a friend if you haven't done it before. And I never put my head underwater unless I have like someone there who can pull me out. I do it for 10 seconds, but I don't want to black out. You know, like you've got more air guts than they.

if I have a friend I'll go under I'll put my head under for a minute anyways it's it's like weightlifting exercise getting back into life you know that kind of stuff as well commonly recommend or the therapy I run an IOP partial we've had a couple of patients with long COVID who are on these like you know medications that just haven't worked like ivermectin or something like that and then just a lot of therapy seems to be what got them back to normal a lot of group therapy and And so I imagine that they might have a depersonalization experience. Yeah. 100%.

Absolutely. Yeah. Yeah. So I think most people can imagine a time where they felt dissociative. And also, I would say the very nature of trauma is to dissociate. Like, I don't know if it's a real trauma unless you actually dissociated in the midst of the trauma. For me, you might not remember the moment of dissociation, but it's very common. to dissociate in the moment of the trauma

or surrounding the trauma or talking about the trauma. A lot of my experience when I'm talking to people about the trauma that they actually went through is you can feel like they get more disconnected from their body. They feel more lightheaded.

They feel numb. They talk different. They talk a little bit softer. This is dissociation. This is it's like the body's defense against something really hard, right? Well, yeah. I mean, I suppose when you're looking at people undergoing kind of traumatic experiences

or very difficult experiences, we often talk about the fight-tel-flight response. Obviously, people may be involved in a car accident. I need to get out the car wreck. You get that fight-t or flight response going. That gets them out of the car wreck, they have the kind of surge of adrenaline going around the body and, you know, the increased kind of oxygen uptake, etc. There is the other response to trauma, which is the freeze response. So this is this idea of almost kind of playing dead.

Yep. And I suppose part of the freeze response is that allows us to freeze and allows us to, I suppose, play dead, is to dissociate. So it can be an adaptive strategy, for example, in a situation where I can't fight or flight my way out of the situation. It can actually be highly adaptive for me to be highly attentive of what's going on around me, but for me to at the same time disconnect. So I might feel emotionally numb and in some way disconnected from what's going on around me as well, which may allow me to survive whatever it is, the assault or the attack or whatever's going on around me.

So as opposed to the fight or flight response is kind of this well, and there's sort of well, often patients will come to me knowing fully what a fight or flight response is, but they generally haven't heard of the freeze response, and it's the freeze response. It kind of is very much associated with these kind of dissociative symptoms. Yeah, I completely agree. I would add one little thing that I've noticed

is that the fight and flight response, tends to happen, it's more, yeah, it's that sympathetic nervous system. Sometimes there will be a, like a pause in the fight-and-flight response where they're surveying the surroundings. It's a hyper-vigilant space. That's not a freeze response. So you'll see, you know, like if a wild animal is sensing danger, they will get very still and they'll look around.

but they're still ready and mobilized for action, right? Yeah. The freeze response, this immobility, the shutdown, which, you know, if you look at like child abuse or adult sexual assaults, I would say the majority report a high level of paralysis. Like 88% in child abuse, 75% adult sexual assaults report a moderate high level of paralysis. And I would say everyone has the capacity to do it. So, for example, David Livingston, there's a famous quote.

He said, he got attacked by a lion. And he froze up and he said it caused a sort of dreaminess in which there was no sense of pain nor feeling of terror, though quite conscious of all that was happening. And so we know in that sort of immobility shut down, association, we have decreased activity in the brain, decreased activity in the right anterior insula, which is where we have interoceptive awareness, decreased activity in the anterior cinglet cortex, which integrates bodily responses with behavioral demands and with emotional awareness.

So the parts of the body that are sensing, like, where our body is positioned, what it feels like to have your feet on the ground, that part is actually tuning down in this shutdown, in this immobility. So we go from the fight and flight, and when it's unsuccessful, when we feel like there's no hope, we go into this shutdown place. And so I'm curious, if you see this as kind of like where people get stuck for a prolonged period of time in this depersonalization, de-realization, like, are we talking about the same thing here, different manifestations of this sort of shutdown, what do you think one of the theories behind why this disorder happens is um well what i suppose in your biological explanations is they found that people with this disorder have this kind of

decrease uh sorry increased prefrontal cortex activity and this and that increase in prefrontal cortex activity shuts down parts of the limbic system or part or shuts down the limb system, it has an inhibitory effect on the limbic system, which can leave people feeling this kind of very emotionally dead state, which is what people will describe with this disorder, at the same time as feeling highly attentive to the surroundings. So one of the theories is this is why the kind of disorder sort of, I guess, emerges or can emerge or one of the neurobiological explanations. there is a cognitive behavioral model of the disorder as well

which suggests that people, I mean, look, if you're involved in a very traumatic incident and you experience this, I suppose, this freeze response or this dissociated response, you may say to yourself, look, I'm feeling this way because I've been through some trauma and once I've settled down this deep personalisation, derelization will go.

What the cognitive behavior model suggests, actually, is that for some people, they become fixed on this symptom, and they insert a catastrophic, a narrative, a catastrophic appraisal, so they may say to themselves, I've been through this traumatic incident. I'm feeling this very strange way, perhaps this is a sign that I'm going mad, or perhaps this is a sign that the trauma has done something bad to my brain, that I can never return from. that then creates a cycle in which the individual experiences more anxiety because of the catastrophic appraisal.

That increased anxiety then creates more depersonalization and de-realization, and then people go around and round and round on that loop. So that's one of the explanations to the disorder, that depersonalization, de-realization is a common experience to have and will be particularly common after a traumatic incident. what um for some people it's things to a catastrophic appraisal about what that means and that's why they then develop the disorder i think that's i think your your emphasis on that and my emphasis on that and repeating that this this idea that you'll have people have a dissociated a dissociated

experience a derealization experience it's the appraisal of that dissociation which really changes the nature of it long term because you could have a lot of fear about that appraisal. You could think, and I think it's helpful to maybe move away and broaden this to all sorts of physical symptoms we have. Like if you have a back spasm

after you do some squats or deadlifting, and you imagine this idea of like, oh, I'm bone on bone, or I'm like going to be harmed forever. That attribution will change how much spasm and the feeling of the spasms and the pain with the spasms, how long the spasms are there. I know this because after weightlifting for a number of years,

and now when I feel it, I'm just like, oh, it's a back spasm. Yes. And I just move on to back spasm and it goes away, right? it's the same thing with heart palpitations. Like let's say you had heart palpitations and you're like attributing some incredibly high meaning of like future pain and distress. Like this palpitation is going to give,

is atrial, is going to give me a stroke or it's going to give me this, you know? I know because I've gone into like AFib a couple times in my life and I've had heart palpitations. and it's like at first when I had it, I had this incredible fear about strokes because that's what I knew, right? I went and saw cardiology,

they said, look, at your age, at your physical health, your risk of stroke is the same as anyone your age. It's very low. And immediately, the meaning changed, you know? Yes. Or I had heart palpitations for a while, and I thought it was aphib, but it wasn't aphib,

it was just premature contractions, high stress, high cortisol, levels, you know. I had this cardiologist friend that I lifted with and he was just about 10 times he told me, dude, you're going to be okay. It's like nothing. It's like I see this all the time. It's, it's, it's, his anxiety level about it was so low because it was like such not a big deal for him, right? Yes. And it changed my meaning of it. And the meaning that having the meaning change made the actual thing decrease. Or I just like didn't even care if it happened, you know? So I think it's so hopefully that theme of like the the value attribution that we put to things and put to this symptom of dissociation, depersonization, de-realization is so important, right? Yeah, 100%. I mean, the model, the cognitive behavioral model, this is developed by a psychologist called Dr. Elaine Hunter, who's based in the UK. and their colleagues.

I mean, the cognitive variable model relies heavily on the panic disorder model, really. You know, with people with panic disorder, like you're kind of saying, they get a heart palpitation. Most people may say, oh, that's just me, my heart fluttering or I'm stressed or whatever. The person who goes on to develop panic disorder says, oh, this is terrible, I'm going to have a heart attack. that obviously then kind of increases anxiety, which increases the chance of them, you know, having more heart flutters or makes them hyper-aware of their heart,

those kind of things, which kind of creates this kind of cycle. And this is what the personalisation disorder, cognitive behaviour model relies heavy on, which is this idea of this appraisal. How does the individual who is experiencing this dissociative symptom appraise what's going to. on for them. If they're praises to something regular, something kind of normal in inverted

commas, that it's just that they're tired or it's just that they've gone through, I don't know, a bad experience with a drug, then as the situational factor reduces, so does the dissociation. For the people who've gone to develop this as a disorder, they insert this catastrophic narrative, which is what I did. So I became convinced that, I'm experiencing this symptom. That must be a sign that I've done some irreversible damage to my brain. Clearly, that appraisal is going to make me more anxious because there's very little I can do about it.

It's something that's happening to me. It's permanent damage to my brain. There's no going back from this. Clearly, I'm going to become more anxious. What happens when we become anxious, we're more likely to dissociate. So we end up in that kind of just cycle, just going around, around, around, around.

Yeah, okay, so even before the CBT model of this, I would go to, I would go way back in history to Marcus Aurelius, right? Roman emperor, here's a couple quotes. Pain is not due to the thing itself, but your own estimate of it. And this you have the power to revoke at any moment. Here's another quote. If you are distressed by an external thing, it is not this thing that disturbs you, but your own judge. about it and it is in your power to wipe out that judgment now you know and so it's like it's your estimation of this thing that's happening to you that you actually have some power over and i would

say for for dissociation my theory on someone like you who's a little bit more prone to dissociation which by the way i am as well like even as a kid i could tell you memories like where i dissociated different things. I think they tend to be higher affective empathy and higher trade openness. And maybe, and I would say

it's the, it's almost like the patients that I have who are three standard deviations above the mean in openness tend to dissociate more easily. What do you think? And I know this because I actually do

the, I actually do the big five. on most of my patients. Okay. If you want, I'll run it on you so you can see what you do. Absolutely, yeah. You have more experience to this than I do, yeah. The third thing I would say is neuroticism. I tend to see patients who are higher neuroticism.

They get stressed out more easily to things. Yes, yes. But it seems that it's like the high openness people. It's like those are the people that, you know, the artists, right, the people who are more creative, naturally, high openness, high creativity. and then high affective empathy because they feel so intensely other people's emotions.

So cognitive empathy is you can tell them what they feel, you can read them, but you may not feel it, you know? So you can be a psychopath and have no affective empathy and have normal cognitive empathy because you've learned it through society and watching people and becoming a keen observer of people.

Notice I throw in keen there. Isn't that interesting? That's a word I usually don't use. maybe because I'm talking to you I don't know do they use that in the UK keen what do you mean by that we like

is that like a normal word that gets thrown in there yeah if you're keen on something you like it a lot yeah yeah that's funny so it's also the name of a really bad band oh this so okay so they have these people with high

affective empathy feel into other people's experience more commonly. So you're a psych nurse, you probably have higher affective empathy. You care about people. You see people suffering. You want to help them, right? And so because I'm very high affective empathy, when someone's dissociating in front of me, like I will feel some of that dissociation when they're having a migraine in front of me. Like my brain may start to hurt. I remember one person who had stabbing headaches. And it's like, it would like come on all of a sudden. I remember like watching them like I am during the interview. And then all of a sudden, like my brain just jolted. And I was just like, what?

And she's like, you could feel that? And I'm like, yeah, what was that? She's like, that's my stabbing headache. And I'm like, oh, my gosh, that's awful. Yeah. Okay. So I'm emphasizing alternative narratives that someone can have about having a dissociative experience. Right.

So instead of telling yourself, I'm going to die, this is always going to go on, this is horrible. it's a different narrative to think, oh, maybe I'm having this because I'm highly creative, I'm high stress reactivity, so when something very stressful happens, I feel that stress more intensely than most people. Or I feel I'm just picking up more stimulus from the environment than most people.

Like the highly sensitive child is someone like yourself who just is pulling in more stimulus than most people. Now, if you're someone who loves to go to Disneyland, like that level of stimulus is your cup of tea, you're not a highly sensitive child, okay? Like you're, and you're not a child. But it's the person who's wired that way, right,

who just pulls in more information and stuff from their environment that I think it can be overwhelming if they pull in too much, if they're having, so it's like a sensory diet is what we do with our kids, for example, where it's like, because me and me and my wife are both highly more on the higher sensitive spectrum our kids are just a beautiful mixture of that and so for us it's like nature it's like we need more nature than most people we need more downtime we need more reading you know we need more of that sort

of reflective space so if so i'm putting out like an alternative narrative that someone can grab onto instead of the catastrophizing narrative I mean, that is the, I mean, I really like that way. I've actually never heard of it been described like that, but that is a lovely counter-narrative to a catastrophic appraisal that somebody might be putting onto this condition. I mean, ultimately, I think what we're saying is that this is kind of, like I said at the beginning, this is a spectrum, isn't it?

Like, to be a human being, really is to be somebody who has the ability to dissociate So this isn't an inherent, although the individual disorder might be experiencing this as a negative experience, it's not an inherently negative experience. And in actual fact, it can actually be for some people, even an enjoyable or desired experience, which people are often surprised by, but I used to work in drug and alcohol services for a number of years. And we'd have people who would take the drug ketamine. Ketamine is a dissociative drug. it brings about these experiences. So that's kind of like, you know, so there's people out there who are kind of paying a lot of money

and risking getting arrested and risking, you know, life and limb to experience what I found out was a, I found to be a horrendous experience. We have people who experience kind of, sort of transcendent, transendent kind of religious experiences who, as part of that experience, as part of the rituals,

they will start to dissociate and they view that as a very positive thing. I know for me myself, I have this ability to dissociate that I can bring on if I want. I used to run ultramarathans for a few years and, you know, kind of at mile 45 of a 50 mile race, it was kind of quite nice to just tune out for a little bit and numb myself to the pain. So I suppose the experience is a human experience. it is not inherently a negative experience. In fact, for some people that can be an entirely desired and wanted experience, it's just for some people who've gone to develop the disorder.

But unfortunately, it's that catastrophic appraisal that they put on it, that I've done something wrong to my brain, I'm going mad, the weeds, you know, destroyed my mind, whatever. That's what turns us into disorder. Very interesting that you would, it would take you that many miles to get into the dissociation. Isn't that interesting? I mean, could you get into it after like five miles?

Or was it happened? Did it have to be 40 miles? No, no, I can get. I mean, if I think about it enough, I can bring it on. Oh, okay. Wow. You know, and to me, is it so happens. When I experienced it, I just kind of say, well, this, I'm just experiencing this.

And then I come to try out of something else and it goes. But I use it as a lot of. little bit of a sort of a sixth sense. So if I'm stressed or overly tired at work, say, I will go on to experience some dissociation. I will simply say to myself, this is a sign that I'm stressed and tired. So my reaction to that is not to do something about the dissociation, is to do something about the stress and the tiredness. And once I, once I saw out those factors, then the dissociation. or just go. So I use it now as a sixth sense to guide whether I'm,

whether I need to do something about kind of, you know, stress levels. So it's a useful thing for me to have. Yeah. I think it's a really good sort of, it's an alternative narrative, right? The narrative, the story that you're telling yourself is I'm stressed and I'm tired. Therefore, I need to rest and take care of myself. Absolutely. I think these are really good narratives as well.

Like if we have kids that are dysregulated, like let's say you have a kid, and it's like this kid isn't Disneyland, it's towards the end of the day, and they're like just absolutely disregulated. It's like, that kid doesn't need a spanking. What they really need is less stimulus. Yeah.

You know, it's like they need some nature, they need some healthy food, they need, you know, some comfort. right so yeah it's it's the narrative that we put on things i'm thinking i'm thinking as well like yeah i like the idea that there's gradients of dissociation like at the lowest level i would say you know when you're driving home if you forgot how you got halfway home because you were thinking about some podcast like let's say you were listening to this podcast you just dissociated You exited one part of your experience

and another part of your experience. Yes. Come back to cold plunge. Sometimes I'll be suffering in the cold plunge and I'll start to post something on Instagram. And just the focused ability to think about what I'm posting to write it takes me completely out of the cold. So it's like one time I was in there for like nine minutes

and I was like, wow, that's the longest I've ever been there. And so it's like, you know, that's another thing. It's like focus can take you out of some painful stimulus. Dissociation. So that's one level of dissociation. People who are smoking marijuana and they've smoked for years, I usually don't, I've had a, well, let me see, I've had one of those patients who all of a sudden started to react poorly to marijuana.

Worked well for years and then all of a sudden it was awful. and he got completely off of marijuana. He came to see me. He was really struggling with it, and it was freaking him out. And you could see the fear and the attribution, right, of what this meant. Am I going to be like this for the rest of my life?

It's incredibly scary. And so if you're listening to this episode, and that's where you are today, know that you are not alone. That's where a lot of people end up. And you have so much pain that you're looking for a solution. And so you're listening to this.

because you've like Googled it and now you're trying to figure out what do I do about this right 100% 100%. I mean like I said before kind of weed is a very common vehicle by which people develop this disorder and it's usually involved some level of panic during an episode of weed's use of marijuana use and which then brings about so intensifies the dissociative experience that people naturally have when they smoke weed. It tends to be that then people put this catastrophic appraisal that the weed has done something to my brain. I've got so high that I've not come down or I can't come down. And that then creates that kind of vicious loop that we talked about earlier of increased anxiety

and increased depersonization. What was the, like, so you had it for two years. How did you exit out of it? Like, what was the journey for you specifically? Yeah. So, I mean, the background is that I was studying to be a psychiatric nurse at the time, which was a very challenging and kind of difficult experience. And I had several of the kind of social stresses going on,

sort of the relationship difficulties in those things, which kind of were just feeding this situation in which I was becoming more and more anxious. And then obviously that creates more opportunities for depersonalization and de-realization. my, like I said, my theory was, look, there's no way out of this. I've got this permanently because I've had it 24-7 for almost two years. There's nothing I can do about it. I've got this brain disease effectively. And I didn't know what to do.

So one day I just took myself off to the accident and emergency department. You call it something different in the US, you know, the emergency treatment department at the hospital. and I saw a practitioner there, a mental health practitioner there who seemed to understand sort of what I was going through, but I don't think understood fully about this being a disorder. He sort of sent me on my way with, I think, 5 milligrams of diatopam. And sort of unbeknownst to me, he rang my university up and said that Pauls attended the hospital.

I think you know you need to look to pull him off the course potentially and I got a phone call for my tutor in the morning and she she said right look you're going to come off this course just for a period whilst you get yourself sorted so during that time a friend just one thought on that I mean that feels like a violation that he reached out to the university like that yes in America that would be like a huge HIPAA violation I felt angry, yeah. Yeah. Now, as it so happened, looking back, that he did me a huge favor.

Okay. So I came off the course for a period and just I was living with one of my best friends now, who's actually trained to be clinical psychologist and he said, well, you're doing nothing. We're off this course. Why don't you come along to the gym with me? and where they'll go along to a spinning class together. So I've nothing to lose,

so I'd go along to a spinning class. And the intense nature of that experience, so it was kind of a dark room, it had like disco lights going, the music was really loud, the trainer was kind of shouting at you, you know, come on, go faster, go harder, you know, on the bike, my heart rate going, everything.

Just for the 45 minutes that I was on the bike, I didn't associate. and I described that the spell was then broken. My belief is I've done something permanent to my brain. There's no going back from this. I have this thing 24-7. I then go on a spinning bike, and for 45 minutes I don't associate.

My belief that I've done something to my brain is permanent is therefore disproven. And from then, over the course of the couple of months, I piece together more and more periods where I didn't dissociate to kind of eventually make a time where I just didn't associate at all. Now, my narrative to myself afterwards, you know, the years afterwards was that, look, the reason I got better was because I engaged in sport, engaged in exercise, and, you know, to this day I still engaged in a lot of exercise. But actually, I've also realized that the practitioner who rang the university up and the university was bringing me off the course that actually just massively reduced my stress levels. So obviously I wasn't having to attend lectures.

I wasn't having to go on placement. I wasn't having to do essays and assignments. And I wasn't having to pretend to be normal. All that kind of reduced my stress levels enough that it kind of created this environment where I could start to recover and heal myself. And I did. And after about two or three months,

I was then back on there, back on the course. That's good. Wow. Yeah, I think I think that first biking incident, you know, it kind of took you out of that shutdown into the fight and flight, right? He's yelling. You're pushing yourself really hard. And then somehow the message in your brain was like, hey, you don't have to get stuck in that dissociated place. Like you got yourself out for a bit. That means you're not going to be stuck in there forever. Correct. you know exercise is also a good treatment of anxiety and depression you know and so 100% it and decreasing the

experience of stress or you know allowing you to be more resilient to stress I talk a lot about in the podcast progressive exercise thoughtfully progressive so that you can slowly raise the bar at which the amount of stress would lead to a dissociation for a example, or lead to other maybe less advantageous coping strategies. Although I think dissociation can be a coping strategy from time to time. Like you said, a lot of people like to dissociate. Drinking alcohol, you kind of dissociate. It's like a happy trance or whatever. People with borderline personality disorder, I have a theory that whenever they hit the hospital, they've usually been dissociating for a couple weeks.

And jarring them out of that dissociation with meds doesn't take very many days. Someone with mania comes to a psychiatric hospital. To get them out of mania takes seven to ten days. Someone with borderline personality disorder, they can flip out of the dissociation, whatever suicidal funk they were in within a day. or two. You know, I don't know if you've seen this.

It's very interesting to say this because I went into this profession, you know, now I work in a community mental health team where I'm day and day out meeting up with people with borderline personality disorder. And, you know, obviously one of the diagnostic criteria is that people have kind of severe dissociates of experiences, right? And I was thought, well, I'm going to speak to these kind of people who are going to assess their symptoms. They're going to tell me that they dissociate.

And I'm going to say, that's really bad that you dissociate. that must be really awful for you. And in actual fact, a lot of them would say to me, no, I really enjoy, or not enjoy it, I really find that experience is quite helpful because when I'm completely emotionally dysregulated, then I'll dissociate and it'll just, you know, I'll take a backseat to my emotions.

So again, it's going back to this idea that actually it's not an inherently negative experience. Now, that might be a maladaptive coping strategy for them. You know, there may be other better ways to cope with that emotional this regulation, but for them it's not perceived as a negative experience. I think going back to the kind of exercise side of things is a psychologist once said to me, look, the reason why the kind of exercise that you did was really helpful is that when you are exercising that intensely, you literally cannot think past your next breath, let alone

ponder about, you know, dissociating. There's no opportunity. I was a little bit, kind of a little bit, some nervous and anxious about doing an interview here, right? So I, you know, thought of what I'm going to do with a morning.

So I go off to the gym and do a brisk walk on a treadmill and I'll, like, run, you know, I'm not thinking about the interview. I'm just kind of thinking about one step in front of another, what's my breathing doing. You know, it just drags you out of those,

those kind of negative thoughts that you have. Yep. Yeah, I did some, uh, squatting, deadlifting this morning. And when you're deadlifting, there's nothing else in your brain. Other than I'm lifting this thing up, let's keep the technique good, you know. I don't know if I, I don't feel pain.

I don't think I feel pain, but I feel, I mean, it's just like if I wasn't awake, now I'm awake. Like, everything in my brain is awake when I deadlight, like, you know, it's, it's. Well, I think even the anticipation of it, isn't it, that you, you got this large weight to lift and you're nervous about potentially not being able to lift it and that kind of thing. So you're really kind of focusing on what I need to do, the technique, what does this look like? I used to be like that, but not anymore. Like there was, when I first started, I would say there were days when all I could think about

was the workout at the end of the day, you know? Like, but now I'm like, I just go do it. Don't think about it too much. I mean, it's like, it's almost boring, right, to some degree. And I think actually that is a good place to arrive if you have depersonization, de-realization. It's like to move from it's incredibly fearful to have this to it's like it's boring to have this. Yes. Well, there's a degree, isn't here? And this runs across a lot of kind of therapies, isn't it? It's that actually our natural inclination is to fight. So we have these, whatever the mental health experience is, we don't like it, we fight it.

And that just persists, make the disorder persists. And that actually kind of acceptance is maybe a good start in place for change to happen. The kind of analogy isn't it kind of like this sort of sinking sand analogy where a quicksand, if I'm sinking in quicksand, my natural inclination will be to wrestle and pull my way out of it and, you know, try and wriggle out of it. And obviously that just makes me sink further. if I accept kind of where I am and if I just actually just lean back or lean forward and spread, distribute my weight, therefore I don't sink any further. I kind of use that analogy with the kind of service users and patient that actually to begin to recover, sometimes we need to accept where we're at. At least then we're not fighting.

And I think that's the case with this disorder as well, that people find the de-realization, depersonalization, a very, very, distressing experience for whatever reason they do and their natural inclination is to fight it. The cognitive behaviour model then suggests that actually this fighting just creates more opportunity for this disorder to kind of take place because we may start to symptom check. So we may constantly be on the lookout for depersonal and de-realisation. We may be constantly on the internet looking for answers about how to fix this thing. we may engage in avoidance behaviour so we may just kind of shut ourselves off and not leave the bedroom

we may pretend to act as though we're normal when we're kind of not feeling normal and all these things all these things do is just create more opportunity for this dissociation to become entrenched so that's the kind of second cycle so you've got this initial cycle with the anxiety The catastrophic narrative creates anxiety, and that creates more dissociation.

The second kind of cognitive behavior or kind of cycle is a kind of maintenance loop where people engage in kind of behaviors which just kind of prolong the symptom. Yeah, I had one patient who was spending about eight hours a day reading about his potential medical issues. It was mostly anxiety that he was.

mostly anxiety that he had, but he would spend about eight hours a day. And yeah, so the loop, if you're not, if you haven't experienced this loop, it can be big. Huge. Yeah. Huge. I think you'll see, you kind of on, you know, I delve in and out of these kind of Reddit forums. Okay. You've got kind of depersonalization, de-realization, Reddit.

And it's just, it's literally just people expressing that they've got this thing and it's absolute hell and it's awful and they don't know what to do. And then obviously people are just kind of reading this and then commenting on it. And it's just, you can tell people are just kind of obsessed with this kind of symptom and are kind of just looking for answers on the internet. And it just must be so frustrating that the internet doesn't come up with like this, oh, you just take this pill and then you just say these words to yourself and then you recover. And so people get more and more frustrated with themselves and with the internet and with kind of life that they're experiencing this symptom, which just creates more.

and more anxiety, which creates more and more opportunity for depersonization, de-realization. Yeah, sometimes these forums and the Facebook groups, and, you know, it can become a place of venting, of one-upping each other's horribleness and symptoms. Yes. And the self-help that is offered is oftentimes poor, if any, You know. Yeah, really cool. Yeah.

And so you can get stuck in this like loop. I mean, I remember when I would first have this thing, I thought, well, I'm going to go on a forum. So I found a forum. And I think the first thing I read was somebody saying that they had this thing for 14 years. And I was like, in one thing, thinking 14 years. Like, and all that did just create more anxiety. And obviously, the more anxiety I feel, the more I dissociate. So it's, yeah.

So I'd say that if anybody's listening to this. with the disorder, my recommendation would be, don't use the forums. The only thing you should really be reading online is of people who have recovered from the disorder. That's a good point. Recovery stories, of which there's plenty of them out there. Yeah. And I bet you get a lot of the people who haven't recovered posting the horrors of their experience. Partially they want empathy. They want they're desperate. They're reaching out. They want something. to be able to help them. But there's a huge selection bias, isn't there?

You know, those people on the forums are the people who haven't recovered. The people who have recovered aren't going on the forums. Right. I get a number of people who reach out to me and they're like, I want to come on your podcast and talk about how much I'm suffering. I'm like, well, have you recovered? They're like, no. And I'm like, well, then that wouldn't be a podcast interview.

That would be me doing therapy, which, you know, you're not in my state. But the time and a place for that. Yeah, you should get a good therapist. You should be, and, you know, the cognitive behavioral model, you know, there's studies on it. But I would say any good therapist should be able to help someone with this. I mean, I really think any therapist should be able to help. Any decent, you know, therapist should be, you know, and therapy takes time, right?

So it's not going to be a cure in one session. It's like how long does it take most people to get out of, like, 75,000? percent of people get out of depression in like 50 sessions or something like that. It's like it takes a while to get out. Now, if you look at CBT for depression, you know, big meta-analysis just came out. The way that I read it was that about 20% more than placebo or the weightless control got better. So 20% more is not 100%. Right? 10 sessions is not going to be enough and 12 sessions is not going to be enough

for most people to get better. So it's a journey. Most people will invest to do the deeper work so that they can get better, but it's important to realize it's an investment. And I think the number one reason why people don't go to therapy is they think it's going to be too expensive. You could look inside your insurance.

If not, you could look at training programs, programs. Young therapists are sometimes just as good as old therapists. It's like they're motivated to help. And so getting, getting into a person that you can afford with your budget, I think is obtainable for most people. I know the university I'm a part of, we even have like a county clinic that we participate in. And so people with, the state level insurance can get therapy there. So it's available. You just have to be curious.

You just have to look. I had one patient even go. I don't know if I would give this as advice, but they found a really good doctor overseas that was doing therapy over video. Yeah. And it was like a quarter of the price of what it would be in like the U.S., you know?

So, okay, so psychotherapy, I think is very important. And yeah, any other thoughts on psychotherapy before we move on to medications? So, yeah, I mean, I think, look, I think the cognitive behavioral model is, I mean, I believe this kind of explains why I suppose to send it into this disorder. I mean, in terms of kind of evidence, there is a trial, I think, from 2005. I think it is involving a reasonably small number of patients. It was an open label study. And they found that they had good success in treating the disorder.

using a cognitive behavioral approach. I am aware that the same team, I think, are in the recruitment phase, I think, of a, for another trial looking at cognitive behavioral therapy for this disorder. And I think the results should be published around about 2024, 2025. So I'll wait that. I really wait excitedly for the results of that study. Yeah. So, I mean, okay, so this 2005 open.

study involving 21 patients treated with the CBT saw significant improvement in measures of dissociation, depression, anxiety, and general functioning. With 29% of the patients no longer meeting criteria for the diagnosis at the end of treatment. So it's kind of in line with what I said, like if you have shorter term treatment, CBT, 20%, 30% are going to get better. Okay. That being said, continue with treatment, right? 12 sessions is probably not enough. 20 sessions is probably not enough. Just continue. If you have a good provider that you feel you trust, that you can have increased ability to share things vulnerably with over time, I think that is sufficient to be helpful. Yeah. That being said, share this episode with your therapist and on the psychiatrypodcast.com as well,

we will have this article, which has all the links to the studies. So your therapist can, if they, if they don't know much about depersonization, de-realization, that they can learn some, I would say that's part of what you could do to sort of help yourself out if you're already seeing someone that you trust. You know, I think you'll benefit from doing the deeper work. Okay, let's talk about psychopharmicology.

Yeah. No FDA approved medications for this disorder. I think that's the first thing to start out with. And there's a lot of smaller studies. Right. And I was reading through what you found, and I think we should go through it, just because it's good, and we'll link all these studies in the article. So, yeah, where do you want to start?

Yeah, well, I suppose, just to reiterate, yeah, this is a little bit wild west in the sense that there isn't an algorithm that we're going to be able to give you here, which says if somebody presents with this disorder, this should be what you've prescribed first. And if that doesn't work, this should be what you prescribe. And there was a study, I think, from the early 2000s in which the team who treat this disorder, I think got 117 of the kind of service users, their patients, and basically said, you know, what treatments have you had before and, you know, has anything kind of worked?

So obviously people listed that they've had been unnecessorized and psychotics and axiolitics and whatnot. And it wasn't found through that study, although it's a very problematic study. It wasn't found that there's any medication that particularly kind of stuck out. So I suppose that's the kind of background here in which we'd be talking about medications. I mentioned this, Simon et al, 2004. It was a double-blind placebo-controlled study involving 54 patients. with DSM4 depersonalization disorder, and they found that fluoxetine was no better than placebo.

So yeah, so in terms of the antidepressants, I mean, that's the major trial involving antidepressants, which is the SSRI, rightly you say it was fluoxetine. Now, what they did find, actually, is that the patients in the fluoxetine group actually did improve more than the placebo group. However, when you controlled for the anxiety and depression or for anxiety and depression, it actually was the anxiety and depression that had actually improved.

Now, what they kind of sort of recognises actually paid some patients with the depersonalisation just felt like they were less bothered by the personalisation. And what they actually say is that a win is a win, right? So whether you've reduced the anxiety and depression and that reduces the dissociation some way or just make somebody's life a little bit more manageable, then it may be worthwhile trialing an SSRI for somebody with this disorder, despite the fact we don't have a very robust kind of evidence based to, in which we might be able to suggest that this is a very effective medication. I would caveat the SSRI use, which is something I mentioned in the article,

which is obviously some patients can experience this kind of numbing effect with SSRIs, which may exacerbate some of the symptoms that people experience with this disorder. So I think perhaps judicious use of these medications may be called for. So they, I'm just looking at this study and they said, finally, a categorical analysis of responder status reveals a 24% response rate on fluoxetine. and a 20% response rate on placebo. The P value being 0.73, so there's no difference between those three,

or two categories, which is not hopeful for me. I mean, as a provider, and I see that, it's like I'm not going to reach, like unless I'm trying to treat the anxiety and the depression, like why would I use that? Absolutely. Well, I think, I guess in terms of the other anti-depress,

I mean, the MAOI, there's no evidence to suggest these are effective. I mean, there's just nothing other than there's one study from, I think, 1988, a case study which suggested that an MAOI was effective in treating a individual with depression who had a kind of depersonalization element to the depression. The tricyclics, there's a little bit more evidence than the tricyclics, So there is a case study from the 80s, which suggested that dysipramine treated primary depersonalization disorder well. And then the individuals who did the study on fluoxetine and also did a study that trials clomipramine against amyprimine. It's only involved, I think, seven patients.

Now, two of those patients who completed the chlamyprimine, phase of that trial, absolutely had a very good response to plimapramine, and I think it was noted that I think when one individual tried to come off to the chlamopramine, the depersonisation returned. So, I mean, there is a long-established link between depersonisation disorder and OCD,

in that some people can really kind of be just constantly symptom checking, they can be kind of almost tortured by obsessional thoughts around existential things, and those kind of things. And obviously, climipramine, although it's not kind of a first-line treatment for OCD, it is an established treatment for OCD. So it may be for a subset of individuals. Chlamopamine might be useful or might be useful as an alternative to people who can't tolerate the SSRIs

due to that kind of numbing effect. Not incredibly excited about the pharmacotherapy in terms of what we've discussed so far. What about... It doesn't get much better. But yeah, it's and you know, the problem is, is that these are small studies, like a case study and individual study, it's not like you can like really control for spontaneously getting better, getting better for other reasons, you know, having it be like a placebo response. So, you know, we have to be a little bit.

guarded with those types of studies. Yeah. We keep going. What else you're finding? I think the medication probably most associated with this disorder as being something that may be effective is Lamotogene. So the reasons behind this are kind of quite interesting. So for individuals who you give ketamine to, I mean, ketamine is a dissociative drug.

I think it increases glutamate transmission. If you pre-treat those individuals with Lamotrogen, the evidence suggests that you get a decrease in dissociative symptoms. So it kind of makes sense that this medication might be affected in treating depersonalization and de-realization. The evidence is kind of really quite nuanced, shall we say. So the team in London here in 2003, they conducted a double-blind placebo-controlled crossover trial involving nine patients.

They sadly saw no benefit when this was used as a monotherapy. The same team have conducted some open label studies, and what they noticed is that there was a 50 to 70 percent, or is it effective in 50% of patients when it was used kind of concurrently with an antidepressant, particularly an SSRI? So there might be kind of some scope to marry a metrodrome with an SSRI. Now, when I said the evidence is kind of nuanced, it's kind of really nuanced because in 2011 there was a trial involving 80 patients. I think this is in Azerbaijan, 80 patients where they used.

Lomotogen as a monotherapy for the treatment of depersonization de-realization disorder, and they found that there was a good response and they defined a good response and adequate response as a 50% reduction on one of the rating scales. And they noticed, yeah, there was a significant response for the patient's treated with Lomotogen. Sadly, the article has been retracted because, in fact, they've plagiarized a large volume of text.

So that has been retracted. Now, I understand that the data was not questions. It was the plagiarism that was questions. How I would say that actually, if they really kind of sloppily kind of just plagiarized a large body of text. So if they've kind of been sloppy in that, then what else have they kind of cut corners in? So I think, yeah, so that's a real problematic study. Now, in terms of the kind of dosages, what the team in London noted was that you, there's potentially really need to can maximize that dose of Lomotrocin,

and I think they were treating people up to 600 milligrams a day with Lomotogen. So if Lomotrogen is going to be used, you may wish to kind of really kind of maximize that dose obviously taken into account kind of then the tolerability of the medication yeah i i've used the motrogen a little bit with dissociation some people it seems to help um like the psychothymia the people with the ups and the downs of the mood can be helpful there's always the risk of stephen johnson syndrome yeah but it does not cause weight gain i still i still vote for therapy and exercise primarily and then thinking about treating comorbid things. Okay, yeah, any other medication groups you want to mention?

Yeah, so, I mean, the other interesting one is the opioid antagonists. Again, mechanistically, this might make sense is when you give somebody an opiate. Obviously, people experience this kind of emotional, kind of numbing effects. and obviously this is kind of why people take it, this kind of pain-free state that people kind of get into, which has particularly, it's been noted when you give somebody an opioid antagonist, particularly an antagonist of the Kappa receptor that in kind of studies have noticed that people experience de-personalization and deregization. So kind of mechanistically might make sense that you may see a reduction in dissociation or emotional numbing if you, initiate an opioid antagonist. In 2001, there's a Russian study which was single blind,

placebo-controlled, involving 14 patients, although not all of those patients had the personalisation disorder. They noticed there was a 71% reduction in symptoms when individuals were treated with noeloxone with re-achieving complete remission. I mean, obviously, naloxone is the agent we typically use to reverse opioid overdose so it's kind of not a kind of long-lasting medication and I think it has to be administered kind of

intramuscularly or intravenously so yeah so further trials have involved naltrexone which is the kind of oral opioid antagonist so there's a couple of trials of interest one 2005 open label trial involving 14 patients treated with a dose of around 120 milligrams a day.

They noted that there was a 30% reduction in symptoms of the personalisation and derealization. And a more recent trial involving naltrexone, it's a German study with 15 patients. They used low dose naltrexone to dosages of around 2 to 6 milligrams a day with 15 patients. not, they weren't specifically treating depersonalization, de-realization disorder. They were treating dissociation. And they noted that there was an improvement in symptoms of depersonization and de-realization in the patients that they treated.

They noted that 11 patients had a lasting, sorry, the notice of reduction in 11 patients in dissociative symptoms and a lasting effect in seven, and they did report specifically to positive reductions and depersonalization and derealization. More studies needed. This is the theme. This is the theme.

Yeah, my response to this is more studies needed, you know. And if you're a provider using medications, you have to comment, like, look, there's just very little data to support much being used. and yeah therapy and therapy and exercise probably I would say I would more supported still

but okay yeah and then antipsychotics very thin we don't need to the studies for people to read benzodiazepines that does not make any sense to me why anyone would why that would help dissociation at all it probably helps anxiety

but I don't think it would help dissociation. I think it actually worsens to association for my experience. Yeah, I think I think some authors have suggested it might be useful for patients who have concomitants anxiety, but I think it's significant caveats with using something like a benzodiazepine in terms of dependence and those kind of things. There's some, again, case studies are around the use of psychostimulants, and it's possibly suggested this might be useful for patients. who experience kind of cognitive symptoms of the disorder, that kind of brain fog. But again, the evidence isn't robust in any sense of the imagination.

What I kind of point to in the article is actually, if you're going to prescribe for this disorder, it is kind of arts as well as science, because, like I said, there's no kind of algorithm I'm going to be able to give you, which says that this is what you should prescribe based on this robust evidence. And you have to be aware that potentially, may make things worse. So, for example, the antidepressants may have, often have side effects of depersonalization listed. Indirectly, some patients may become worse on certain medications due to other side effects. So, you know, are epipypizol, for example, something I guess they commonly

used on the forums. And obviously, that's often associated with things like agitation and anxiety, the same with an arrexone, actually the same with lelotrogen. So you may make underlying depersonization worse due to that mechanism. And the final thing is that actually some medications when you withdraw from them, the benzodiazepines, the antidepressants, the mood stabilises that sometimes people can experience the personalisation as a result of withdrawal

phenomena. So I think we should be honest with our service users and saying that if we are going to prescribe, we're prescribing on very thin evidence and that actually there's a potential that we might make things worse. so I think there needs to be an open and candid discussion with your service user before initiating any medication. 100% yeah.

So with airpaprizole you can get acethezia, which is restlessness. So you have to watch out for that. You don't want to add another issue on top of their depersonalization. I've had some patients who describe something like depersonalization after getting off of antidepressants. So it's not just putting medications on, but it can actually be taking it off. How long does it last? It depends. It would be my answer.

But, yeah, we don't want to add a medication, have it do nothing, and then not stop it before considering a different one. So if you are going to try a medication, my recommendation is try it, give it a trial period, know how long the trial period should be based on the medication. and then if it doesn't work, get them off of it before you start something else. Because the last thing you want to do is just start doing polypharm on someone like this. And I imagine in the forms you see a lot of people where that's the case, right?

They're like on four medications. They're like, I'm not better yet. Yeah, absolutely. Or I'm worse. Or I'm worse, yeah. And then they have the withdrawal effect, you know, as well. because a lot of the times they don't know how to get off the medication.

Providers are nervous to get people off of medications if it's working a little bit. In my research and kind of for setting up the depersonization guidance center the business I operate under, I actually spoke to people online just kind of offering a conversation with them really. And I spoke to one lady from the US and actually her descent into depersonization,

Duralization Disorder was when she was, she stopped Venlo vaccine abruptly. Obviously, Venlo vaccine very short half-life, known for its kind of withdrawal effects. And then she had this kind of strange dissociative experience on it, which she became fixated on, and then it kind of stuck. So her vehicle into the disorder was through medication, or at least coming off it inappropriately, which I found very interesting. Yeah, I'm not surprised. Sometimes people, especially have been on it for a long time,

they need to get off very slowly, and they need to do lifestyle things as well. Like if someone comes to me and they want to get off medications, I'm like, how can we optimize your exercise, your diet, stuff like that, to treat the underlying things that you need treated? therapy, things like that. Okay. So final thoughts. Any final thoughts on this? Yeah. So I mean, look, I think a lot of people are going to be inexperienced with kind of treating this disorder or inexperienced even with recognizing this disorder despite the fact that it's incredibly common,

especially within the population that you're likely to come across. even if you don't feel confident in treating the disorder, I think there is something very simple that can be done, which is simply normalising this symptom. And that patients will often present to you, highly anxious about what's going on for them, highly anxious about whether this thing is going to go away, and actually just simply some soothing words of normalisation

that actually this is part of the human experience. it's often associated with things like fatigue, with stress, with panic, with substance use. That can be very comforting for people to hear. And it may even be very comforting to actually establish a diagnosis with somebody that you're actually expressing. This is a well-understood condition with a clear diagnostic framework for it. And I think then the very final thing is that actually a lot of people, people, because this isn't kind of a very well-known disorder, like something like, I don't know, panic disorder or major depression, people are going on forums, getting all kinds of mixed messages about things, and getting very worked up about it. I think us as clinicians should point to the possibility of recovery. I'm obviously pleased to say that I've recovered and I'm happy to share my recovery story.

and there is plenty of other recovery stories online that you'll be able to find on YouTube that you can point people towards. So I think we're trying to normalise this condition, normalize the experience, depersonization and de-realization is part of a normal human experience, but I think we should also be trying to normalize recovery,

that recovery is very possible and that we can point to several recovery stories and, like I said, I'm more than happy to add my story to the list. And one college student, I'll change a couple of the demographic factors just to hide the identity, of course, but college student, female was at a party, was given what she thought was LSD eye drop, put it in her eye and started just in this incredible depersonization experience, incredible panic. And then it kind of continued where she was wandering around college. now just completely like in this like haze. It turns out it wasn't even LSD. They had given her just a normal eye drop

and then told her that it was LSD and then they were all laughing at her when she was like tripping out and she didn't realize why they were laughing at her. So that was part of the horribleness of the experience, right? And she comes to me and we did about five therapy sessions in a row going back to the memory talking about how

empathizing with her experience looking at the all the different thoughts, hot thoughts, different things going on and then expressing anger towards the inhumanity of being treated that way

and then she snapped out of it. That was it. She started like she came back a month later completely normal. and you know

so sometimes it doesn't take a long journey you know if you're a mental health professional listen to this hopefully this gives you enough tools to listen to someone's story don't let them just fall through the cracks

and go months without treatment you know try to get them in sooner than later because it's very it can be very distressing and then you know exercise

both strength training, cardio may have a role, as you've kind of heard in this episode. It had a role in Paul. Paul's journey. So, yeah, and I love your idea that you've brought forth of this kind of like, what is the meaning that we're attributing to this symptom? And how do we change the meaning? So how do we change the meaning maybe from like this, catastrophic. This is going to be with me forever. Worst case scenario which Facebook and all the

forms may have amplified, right? To, you know, I've had some dissociation in my life. I'm a more sensitive person. I have more empathic. That's a superpower. I'm higher openness. That's a superpower. I'm a creative person. And because of that, I have this propensity to dissociate from time to time. and I'm kind of stuck in it because I went through a really stressful time and because I've been catastrophizing it. So I'm going to stop catastrophizing it. And I'm going to adopt a different narrative, get some help, talk to someone, and see if I can work through it.

I think it's very hopeful. Hopeful, hopeful plan. So, man, this is great. Paul, we are going to have to have you back. I talked about maybe co-interviewing someone who wrote a book on this together. 100%. I think that would be fun.

And yeah, any final closing thoughts? No, I think we've covered everything there. Again, just to say recovery is possible. You know, I'm one of many and I hope we can get more recovery stories out there. Yep. So if you're listening to this, you can reach out to Paul. I'll put, you know, this article on my website

Psychiatrypodcast.com. And if you go there, you can see all the links to his websites and stuff. And we will leave it there for today. We'll miss it with you.