DPD: A disruption in attention and perceptions (?) - Research - Depersonalization Community

Jump to content


Please Read the Community Forum Guidelines Before Posting.


Photo

DPD: A disruption in attention and perceptions (?)


  • Please log in to reply
8 replies to this topic

#1 curiousmind

curiousmind

    Regular Contributor

  • DPSH Members
  • 100 posts
  • LocationBudapest, Hungary

Posted 14 January 2020 - 04:57 AM

I wanted to share a couple of quotes from a phenomenological analysis [link] of DPD by Patrick Mellor from the University of San Francisco published in 2015 titled 'Inside-out Minds: Consciousness, Attention, and Depersonalization'. I would then like to add some comments to his findings. Below in bullet points I have collated some of his findings that I found relevant to my enquiry, but he has a lot more to say than this and I highly recommend the paper in its entirety. They all sound incredibly relatable. 

  • "Sufferers of DPD often [...] report that their sensitivity to minute changes in their visual field is actually enhanced, along with a focus on minute features to the detriment of seeing larger scale patterns
  • "They also report a diminution of perceived solidity and temporal stability of perceptions of objects". 
  • "There is a separation of the experiences of the sounds of words from the meanings of those sounds, and in the case of visual descriptions, from the objects referred to by words. All these faculties still function, but they are no longer experienced as an integrated whole, the person simultaneously experiences an understanding of the words with a sense of hearing alien, meaningless sounds." 
  • "... and are hyper-conscious of complex details of muscular movement in simple tasks, to the detriment of the task itself". 
  • "These perceptual symptoms are usually accompanied by a feeling of detachment from emotional experience, which feels flattened and "as if" it refers to another person, often to the same person pre-depersonalization, who they sometimes describe as having died. Even with this detachment, most of the time sufferers remain emotionally connected to others, it is their internal experience of emotion that has changed, often along with a diminution of reaction to pleasurable and unpleasant situations, stimuli, and activities they previously enjoyed."

The recurring theme here is perception and the mechanism of attention (to what we give our attention to), an aspect of this condition that I think is under-researched and not discussed enough. Unfortunately, as of yet I couldn't find any systematic reviews of attention in DPD from a neurophysiological point of view, but if you have read one before or have previously stumbled across one then please share it here, I'd be interested in what they found. From a phenomenological standpoint, it definitely sounds like there is a disruption in subconscious attention, a peculiar type of attention dysfunction which manifests distinctly from the symptomatology of attention deficit disorders such as ADD and ADHD. 

 

A study [link] conducted by Daphne et al. in 2000 came to similar conclusions following a PET scan analysis, claiming that the disorder is perhaps best described as a "dissociation of perceptions":

  • "Depersonalization appears to be associated with functional abnormalities along sequential hierarchical areas, secondary and cross-modal, of the sensory cortex (visual, auditory, and somatosensory), as well as areas responsible for an integrated body schema. These findings are in good agreement with the phenomenological conceptualization of depersonalization as a dissociation of perceptions as well as with the subjective symptoms of depersonalization disorder."

 

Many of you are aware of the French trial that was allegedly completed sometime in September 2019 [link]. Apparently it will be published sometime soon. This study looks at the effects of rTMS on the Angular Gyrus which I (and others) think  may reveal where some of this alteration of attention/perception is coming from, and the potential solution(s) to this disintegration. The Angular Gyrus is involved in a number of processes related to "language, number processing and spatial cognition, memory retrieval, attention, and theory of mind" [link]. So the study seems to be a promising one.

 

Interestingly, many patients with DPD also report having tinnitus and visual snow. Maybe it's just a coincidence, I don't know, but preliminary research into patients with tinnitus [link] suggest that the Angular Gyrus plays a crucial role in the unnecessary perception of sound. I speculate that a similar mechanism is also accountable for visual snow (though I haven't really read into this condition). From a phenomenological point of view, all of these symptoms are likely related to unnecessary perceptions of detail and a disruption in subconscious attention. 



#2 curiousmind

curiousmind

    Regular Contributor

  • DPSH Members
  • 100 posts
  • LocationBudapest, Hungary

Posted 14 January 2020 - 07:23 AM

Just to add, I don't mean to suggest or in any way imply that stimulants will solve the DPD-specific attention problems. As mentioned in the original post, regarding DPD there likely exists a disruption in what I informally called "subconscious attention", it is a very peculiar type of attention dysfunction which manifests distinctly from the symptomatology of attention deficit disorders such as ADD and ADHD. 

 

There is only minor evidence to support that stimulant medication (which is used to treat attention deficit disorders) may have benefit to patients with DPD, but this is not at all conclusive. 

  • This single-case report [link] suggested that Ritalin (methylphenidate) may be effective for treating DPD as they concluded that "based on the results obtained in this case, methylphenidate may be a good anti-depersonalization drug." 
  • Another single-case study [link] reported similar improvement with Adderal (also a stimulant). "Here the case of a woman with severe dissociative symptoms that were markedly improved with the administration of mixed amphetamine salts is discussed."
  • Anecdotal evidence is mixed, some may experience an increase and others a decrease in DPD symptoms following the administration of stimulant medication [link]

Otherwise, the only recent larger study I've read about is one conducted in California State University Northridge lead by Tanya Oleskowicz and Sara Berzenski titled "How does taking Ritalin affect depersonalization-derealization disorder patients?" [link]. Despite its misleading title, the study oddly observes the effects of Ritalin on non-DPD patients: "This quasi-experimental project featured a sample of 26 participants: 8 “treatment” individuals, taking Ritalin for ADHD symptoms, and 18 controls, not taking Ritalin or other stimulant medications. None of the participants had clinically-significant DPDR (a Cambridge Depersonalization Scale (CDS) score of at least 70; the mean CDS score endorsed by both “treatment” and control participants was between 16 and 18)." So, to my understanding, the aim of the study is to examine how the administration of Ritalin effects DPD symptoms based on the Cambridge Depersonalization Scale (CDS) in non-DPD patients, thereby making speculations as to whether or not Ritalin could be effective in treating primary DPD symptoms. Heres what they found [link]:

  • "Our initial hypothesis- that DPDR symptoms would be reduced at peak action compared to pre-test among individuals taking Ritalin- was not supported."
  • "However, importantly, almost all individuals saw either a sharp increase OR a sharp decrease in DPDR symptoms after taking Ritalin (see Figure1). Because these increases and decreases canceled each other out in the statistical analyses, we were not able to observe an overall positive effect of Ritalin on DPDR symptoms."

Hence, it is pretty unlikely that stimulants are the way to go. Maybe it could help certain individuals, but we don't know. Again, DPD patients likely experience a disruption in "subconscious attention", but this is a very specific type of attention dysfunction which manifests distinctly from the symptomatology of attention deficit disorders such as ADD and ADHD.

 

The attention-related issues in DPD are likely related to a disintegration of the sensory cortex [link]. For this reason, I am speculating that rTMS to the Angular Gyrus will be effective. The French study will likely comment on improvements in attention, and it may also reveal which population of the patients saw an improvement in symptoms, and what those symptoms were. 



#3 curiousmind

curiousmind

    Regular Contributor

  • DPSH Members
  • 100 posts
  • LocationBudapest, Hungary

Posted 14 January 2020 - 02:40 PM

So, what about those who recover through purely psychological techniques such as CBT/ACT [link]?

 

Related to the topic of attentional processing is the subject of "thought suppression", but I am of course speculating a little bit here when it comes to its relation to DPD. There are no studies or reviews of any sort that mention thought suppression outright in relation to DPD. It definitely seems to be part of it though. Wegner D. M. (1994) proposed an account of attentional processing in PTSD/phobic patients; he suggested "the provocative theory of ironic processing, which has been applied to a number of cognitive processes (e.g., mood control, thought suppression) and has received some attention in the pain literature." [link] Alternatively, "several authors (Salkovskis, 1989; Wegner, 1989) have put forward that thought suppression might play a role in the etiology and maintenance of anxiety disorders such as specific phobias."[link] The results of the referenced study were the following:

  • "First, as expected, phobic patients reported higher levels of intrusive and negative thinking [...] than nonphobic patients."
  • "Second, phobic patients tried harder to suppress their negative thoughts than nonphobic subjects."
  • "Finally, in the nonphobic group, suppression resulted in increased levels of anxiety and intrusive thinking. Altogether, the findings suggest that thought suppression is related to pathological manifestations of [...] fear. That is to say, suppression intensifies fear in nonphobic subjects, whereas it appears to be part of the habitual “coping” style in phobic patients."

While I do not think that thought suppression is the core and underlying mechanism in DPD, I do think that it is implicated in the disoder, perhaps to the extent that ironic processing prolongs the impairment that DPD can cause; a dysfunction related to attention may keep thoughts suppressed, further exacerbating the course of the disorder. On the bride side, this is perhaps why many DPD patients, especially those with an early diagnosis have a good prognosis. It is likely that they have less suppressed thoughts to process, and this may be why we see reports of recovery in the name of "acceptance".  Shaun O'connor mentioned in an article that stumbling upon the theory of "ironic processing" had put him on a path to recovery. Many are skeptical of him for the reason that he is selling a programme, but nonetheless it is worthwhile acknowledging that he has recovered, and many others using similar (purely) psychological technique have. In an article [link] he writes the following:

  • "[...] I threw myself into researching the nature of these obsessive thoughts. One of the theories I learned about was Ironic Process, the idea that if you actively try not to think of something, you are bound to think of it repeatedly." 

The entire motto of his recovery programme is, of course, to treat the underlying anxiety.

 

Other resources that promote psychological approaches to recovery (such as anxietynomore [link]) in some way echo Shaun's method. The recurring advice is "don't ignore thoughts", "allow whatever thought to arise", "allow all feelings to manifest" and to "accept the disorder" and so forth. Perhaps by not allowing whatever thought to arise and by not giving space for the subconscious mind to process whatever it may need to process without judgement, the course and duration of DPD is prolonged. Perhaps it is the very veil of DPD that disallows for subconscious thoughts and feelings to manifest; it is the result of a subconscious filtering mechanism that tunes out unwanted and undesired feelings by not giving it attention. I don't know, there is some speculation here. To my understanding, a similar anxiety-based approach is pursued by Elaine Hunter in a clinical, CBT setting at the Maudsley Hospital [link]. This podcast featuring Elaine Hunter goes into more detail [link]. 



#4 curiousmind

curiousmind

    Regular Contributor

  • DPSH Members
  • 100 posts
  • LocationBudapest, Hungary

Posted 18 January 2020 - 04:32 AM

On attention and its relationship to emotional numbing...

 

Sierra and David (the proposers of the fronto-limbic model) have made claims in relation to a disruption in attention, and it is suggested that perhaps the fronto-limbic model itself lays on the foundations of attentional dysfunction. 

  • "It has been proposed that depersonalization is caused by a fronto-limbic (particularly anterior insula) suppressive mechanism--presumably mediated via attention--which manifests subjectively as emotional numbing, and disables the process by which perception and cognition normally become emotionally coloured, giving rise to a subjective feeling of 'unreality'. "[link]

This supports the idea that DPDR is an impairment of attention, and it is important to highlight that it is likely the consequence of this impairment that the symptoms of the disorder are very illusory. DPDR is not anhedonia; the emotional numbing in DPD is not the same as having no emotions. DPD patients have emotions (just as in before they got the disorder) but they are not giving attention to those emotions resulting in the subjective quasi-illusion that the individual has no emotions. This mechanism is subconscious, the patient does not "choose" to suppress emotions per se, but is actually doing so on a subconscious level. So treating DPD as anhedonia (as many on this forum are trying to do) will likely not bear the desired outcome. Anhedonia is related to a disruption in reward circuitry, and is an objective loss of the ability to feel pleasure [link]. This is in contrast to DPDR, where pleasure is subjectively not felt due to an attentional mechanism which suppresses the patients emotional experience, or so the (very compelling) theory goes. 

 

In briefly making the argument that DPDR is a subjective loss of emotions mediated by attention and that no emotions are actually lost as in the case of anhedonia but are rather "buried under a layer of scar tissue"—as a DPDR recoverer once put it [link], it is worthwhile to at least briefly examine this study which compared electrodermal responsiveness in DPDR patients and controls, the controls being patients suffering from major depressive disorder [link].

 

The most crucial outcome:

  • "Contrary to our expectations and to previous studies [17,18], showing attenuated autonomic responsiveness to negative emotional stimuli, we found increased electrodermal responsiveness for DPD patients as compared to patient controls."

When conducting the test on electrodermal responsiveness for those with major depressive disorder, this is what they found:

  • "In our study, the patient controls [those diagnose with major depressive disorder] showed overall less strong electrodermal responses and no modulation by valence and arousal. This pattern, which is in line with previous studies on emotional reactivity in major depressive disorder [46], may reflect a generally reduced emotional reactivity such as anhedonia [47].

Which is opposed to what they found in DPDR patients: 

  • In accordance with Schoenberg et al. (2012) [21], DPD patients showed more NSRs during a rest period, which reflects higher sympathetic lability [48]."

DPDR is not anhedonia. It has been measured that the emotional state of those with DPDR is closer to healthy controls, but these emotions are somehow trapped, and as Sierra and David proposed are suppressed due to an impaired attentional mechanism.



#5 Saschasascha

Saschasascha

    Advanced Member

  • DPSH Members
  • 42 posts

Posted 29 January 2020 - 11:21 PM

Thanks for the insights, curiousmind!

I live in Germany and we do have a specialized DP hospital and the professor of the hospital who has also wrote a great book claims that DP, in short is affect phobia. This fits to your insights that in DP emotions are buried, trapped and not accessible. This is the desired outcome: to surpress emotions too painful to bear.  

I 100% believe that almost all cases of DP have a psychological origin. I'm sorry that I can't add anything to the brain related mechanism. I do believe those "dysfunctional" brain circuits are the result of what is going inside rather than some arbitrary malfunctioning of the brain. In my opinion psychodynamic therapy therefore is the best approacht to treat DP. But: I don't deny that certain medications won't benefit some people and I don't deny that procedures such as TMS can't be helpful. What are your thoughts?

Greetings from Germany !

Sascha

Here is kind of a summary of the doctors thoughts. His name is Mathias Michal by the way:

The self-perception of patients with depersonalization disorder
Depersonalization disorder involves an unpleasant, chronic and disabling alteration in the experience of the self, characterized by feelings of detachment and unreality. Depersonalization disorder (DPD) is the result of complex defense mechanisms, with avoidance of emotions, pervasive shame, lack of self-esteem and conflicting self-images playing a major role. Patients with DPD often suffered from emotional abuse and neglect during their childhood. The illness attitude of the DPD sufferers is characterized by immense feelings of being out of control, helplessness and isolation; regarding their self-representations DPD patients perceive themselves as worthless and inadequate. Concerning the psychotherapeutic treatment it is considered to be crucial to validate the inner experiences of the patients, to bridge the gap between the symptoms and the experiencing self, and to analyze depersonalization as a specific form of resistance.



#6 curiousmind

curiousmind

    Regular Contributor

  • DPSH Members
  • 100 posts
  • LocationBudapest, Hungary

Posted 30 January 2020 - 05:04 AM

I live in Germany and we do have a specialized DP hospital and the professor of the hospital who has also wrote a great book claims that DP, in short is affect phobia. 

Thats very interesting, the term "affect phobia" definitely captures a significant aspect of the DPD experience. 

 

Do you see this doctor yourself? 

 

I 100% believe that almost all cases of DP have a psychological origin. I'm sorry that I can't add anything to the brain related mechanism. I do believe those "dysfunctional" brain circuits are the result of what is going inside rather than some arbitrary malfunctioning of the brain. In my opinion psychodynamic therapy therefore is the best approacht to treat DP. But: I don't deny that certain medications won't benefit some people and I don't deny that procedures such as TMS can't be helpful. What are your thoughts?

I agree. I think that to work with psychic tension in DPD patients is paramount, and should be of primary importance. My observation has been that most people who say have recovered on these forums all attribute their accomplishment to acceptance, alleviating anxiety and not being interested in their symptoms whether they had them or not at any particular time; just living life as normal. This disinterestedness in the disorder likely allows the person to digest any arising conflicts of the subconscious. Of course, this isn't so obvious and established yet either, we can only really speculate and reference the anecdotes. 

 

Here is kind of a summary of the doctors thoughts. His name is Mathias Michal by the way:

The self-perception of patients with depersonalization disorder
Depersonalization disorder involves an unpleasant, chronic and disabling alteration in the experience of the self, characterized by feelings of detachment and unreality. Depersonalization disorder (DPD) is the result of complex defense mechanisms, with avoidance of emotions, pervasive shame, lack of self-esteem and conflicting self-images playing a major role. Patients with DPD often suffered from emotional abuse and neglect during their childhood. The illness attitude of the DPD sufferers is characterized by immense feelings of being out of control, helplessness and isolation; regarding their self-representations DPD patients perceive themselves as worthless and inadequate. Concerning the psychotherapeutic treatment it is considered to be crucial to validate the inner experiences of the patients, to bridge the gap between the symptoms and the experiencing self, and to analyze depersonalization as a specific form of resistance.

A very valid approach. Do you know if he had success with treating patients?



#7 Saschasascha

Saschasascha

    Advanced Member

  • DPSH Members
  • 42 posts

Posted 30 January 2020 - 10:36 AM

He had success in treating patients and he makes the statement in his book that even after years of having it you can get totally rid of it. Sadly I don't know any actual success rates.

 

I also do believe that acceptance and such things have an important role but from what I've seen most people who have had it chronic for a certain amount of time only come out of it if they really face their root problems in therapy. And I believe the reason why not that many people seem to get out of it is because it is brutal. You have to face all the surpressed psychich pain and face very very painful emotions. And it is often times a long time process to really "see the light of the tunnel"

 

By the way, I have had it for the last 20 years chronic. No joke. Not that severe and more derealization-based but yeah. And I have been in therapy for the last 9 months. And for the first time I have actually made progress. I am now able to feel emotions spontaneously again and feel them in whole being: not just on a cognitive level. Every aspect of it has gotten better. It isn't gone and the DR symptoms are still there but overall I really have made lots of progress. The therapist I see treats trauma based disorders such as PTSD and CPTSD. He actually believes that I have light CPTSD. I am not so sure on this one, there are a few threads where people state that DP is basically just a symptoms of CPTSD. Personally I think that rings true for some people and the other ones do experience similar symptoms because DP puts this constant stress on you. Again, I am not an expert. The thing is, the therapist helps me. In every session, I talk about my conflicts, we work on my deep rooted shame with a compassionate approach. Lots of imaginary techniques, somatic things, working with my body to start feeling again. 

 

Lastly, what I observed is that most people with DP have had some dysfunctional attachment patterns with their parents that led to a root trauma.I know lots of people in this forum hate Harris Harrington. But I think what he says partially has great value; Summarized he believes that a dysfunctional attachment, accumulated unprocessed trauma and an obsessive self focus are the things that need to be targetted to adress DP. I believe the gist of it isn't too far from what Dr. Michal says about the disorder.

 

So, yeah, those are all just things I collected over the years and I really hope they are of some value! smile.png



#8 Saschasascha

Saschasascha

    Advanced Member

  • DPSH Members
  • 42 posts

Posted 30 January 2020 - 10:49 AM

Have to add the Harris Harrington guy is "inspired" by Giovanni Littoi, who has been a psychiatrist and scholar in attachment theory. I link you to this PDF: https://www.empty-me..._Attachment.pdf

This is an aspect that one definitely should cast an eye at. Many DP patients seemed to have a disorganized attachment style with their parents or some attachment dysfunction.



#9 curiousmind

curiousmind

    Regular Contributor

  • DPSH Members
  • 100 posts
  • LocationBudapest, Hungary

Posted 30 January 2020 - 05:47 PM

Liotti's work has some relevance, but even more so do the writings of early psychodynamic theorists. The following excerpt was taken from "Depersonalization: a conceptual history" by Sierra and Berrios in 1997 [link]. 
 
"In 1945, summarizing the work of Obendorf, Fenichel explained with usual clarity: ’the experiences of estrangement and depersonalization are due to a special type of defence, namely to a counter-cathexis against one’s own feelings which had been altered and intensified by a preceding increase in narcissism. The results of this increase are perceived as unpleasant by the ego which therefore undertakes defensive measures against them’ (:419). Fenichel also quoted Schilder: ’persons suffering from depersonalization do not lack feelings; the patients merely perceive, arising from within, an opposition to their experiences’ ... ’an intensified self-observation is the manifest expression of this opposition’. Indeed, Schilder believed that depersonalization was a developmental syndrome resulting from excessive narcissistic gratification during childhood. Reacting against subsequent deprivation, the subject identified with his own parents and indulged in persistent self-observation during which libido was withdrawn from the outside world: ’there is no doubt that in depersonalization the individual loses interest in the outside world and loses with it the interest in his body, which, as has been seen in our previous remarks, has a close relation with the outside world’ (:140). For Schilder, some organs (for example, voice in a singer) were particularly involved in the phenomenon of depersonalization because: ’it occurs, as I have shown, especially in organs which have previously been of a great erotic significance’ (:139).5~ Another recurrent psychoanalytical theme has been the view of depersonalization as a defensive process against anxiogenic intrapsychic conflicts." (bold and underlining was added by me).
 
So the idea that this disorder is a result of some intra-psychic pain is not new, and very likely. Also in bold, another supporting statement that emotions are burried, not agone. 





0 user(s) are reading this topic

0 members, 0 guests, 0 anonymous users