Depersonalisation disorder: a cognitive–behavioural conceptualisation

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Abstract

Depersonalisation (DP) and derealisation (DR) are subjective experiences of unreality in, respectively, one’s sense of self and the outside world. These experiences occur on a continuum from transient episodes that are frequently reported in healthy individuals under certain situational conditions to a chronic psychiatric disorder that causes considerable distress (depersonalisation disorder, DPD). Despite the relatively high rates of reporting these symptoms, little research has been conducted into psychological treatments for this disorder. We suggest that there is compelling evidence to link DPD with the anxiety disorders, particularly panic. This paper proposes that it is the catastrophic appraisal of the normally transient symptoms of DP/DR that results in the development of a chronic disorder. We suggest that if DP/DR symptoms are misinterpreted as indicative of severe mental illness or brain dysfunction, a vicious cycle of increasing anxiety and consequently increased DP/DR symptoms will result. Moreover, cognitive and behavioural responses to symptoms such as specific avoidances, ‘safety behaviours’ and cognitive biases serve to maintain the disorder by increasing awareness of the symptoms, heightening the perceived threat and preventing disconfirmation of the catastrophic misinterpretations. A coherent model facilitates the development of potentially effective cognitive and behavioural interventions.

Section snippets

Depersonalisation disorder: associations with anxiety

Depersonalisation disorder is classified as a dissociative disorder in DSM-IV (American Psychiatric Association, 1994), alongside dissociative amnesia, fugue and identity disorder (DID). The definition of the dissociative disorders is that there is a ‘disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment’ (DSM-IV, p. 477). In this respect, DPD has dissociative features in that sufferers experience a disruption in their previous

A cognitive model of depersonalisation disorder

Transient symptoms of DP/DR are common phenomena in normal populations, as are symptoms of anxiety. Cognitive models of anxiety disorders such as those of panic (Clark, 1986) or health anxiety (Warwick & Salkovskis, 1990) suggest that it is the interpretation of these common symptoms that determines whether they develop into a chronic disorder. More specifically, it is the catastrophic misinterpretation of these symptoms as indicating threat that leads to a vicious cycle of increasing symptoms,

Implications of the model for treatment

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

Conclusions

From the existing literature there appears to be compelling evidence to support an association between DPD and the anxiety disorders. The conceptualisation of DPD within an anxiety disorders framework provides us with an empirically testable model and a rationale for treatment. However, the current lack of empirical research on DPD means that parts of the model proposed in this paper are still very speculative and testing of the model is planned for the near future. It is hoped that further

Acknowledgements

Support for this study came from the Col. W.W. Pilkington Will, Cecil Pilkington and A.P. Pilkington Pilozzo Charitable Trusts.

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