Does CBT for Depersonalisation-

Derealisation Disorder work?

Dr Elaine Hunter, Consultant Clinical Psychologist & Chief

Investigator
Rafael Gafoor, Statistician & Consultant Psychiatrist

PCPH Seminar 24.5.22 1

 Overview of presentation
• Introduction and background to this audit
• Depersonalisation-Derealisation Disorder (DDD): phenomenology, epidemiology
and aetiology
• Overview of CBT for DDD
• Evidence base from small published audit in 2005
• Current audit – method, results, limitations, conclusions
• Next steps
• NIHR RCT feasibility study overview

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 Understanding
Depersonalisation-Derealisation
Disorder (DDD)

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 DSM-V Dissociative disorders
Dissociative amnesia
“…an inability to recall important
personal information… that is too
extensive to be explained by
ordinary forgetfulness” including
Dissociative fugue
Dissociative identity disorder
“…the presence of two or more
distinct identities or personality
states that recurrently take control
of the individual’s behaviour
accompanied by an inability to
recall important personal
information…”
Also PTSD “with dissociative symptoms” subtype
Depersonalization /derealisation
disorder
“…a persistent or recurrent feeling
of being detached from one’s mental
processes or body…accompanied by
intact reality testing”
Other specified dissociative
disorders (i.e. mixed/ due to
coercive persuasion/ transient
reactions)
Unspecified dissociative disorders
(i.e. where symptoms don’t meet
full criteria)
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 Defining symptoms of Depersonalisation-
Derealization Disorder
Defined by a sense of detachment and
unreality about the self
(Depersonalisation) and/or the external
world (Derealisation)

Completely subjective, ‘as if’ , experience

– not observable and common as transient
symptoms

DDD diagnosed when symptoms are

chronic, distressing & cause functional
impairment
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 Other symptoms of DDD
 Emotional numbing
 Cognitive ‘numbing’
 Physical numbing
 Perceptual disturbances
 Heightened sensitivity to external and internal
stimuli
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 Epidemiology of DDD
Hunter, Sierra & David (2004) Social Psychiatry and Epidemiology / Yang, Millman, David & Hunter (2020) Journal of Trauma & Dissociation

Non-Clinical samples
• Symptoms of DP/DR: Lifetime incidence of transient DP/DR symptoms ~
34-70%, associated with fatigue, substance use or trauma / Past year – 23%
• DD Disorder: Community samples of current DDD consistently around 1%
in global studies
Clinical samples
• 5-20% in out-patients and 17.5-41.9% in-patient samples
• Prevalence rates vary in studies of specific disorders:
1.8-5.9% (substance abuse), 3.3-20.2% (anxiety), 3.7-20.4% (other
dissociative disorders), 16.3% (schizophrenia), 17% (borderline
personality disorder), ~50% (depression).
• The highest rates were found in people who experienced interpersonal
abuse (25-53.8%) and panic disorder (up to 80%)

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 Associations with trauma?
Simeon et al., 2001 & 2006; Michal et al., 2007

• Strong associations between

childhood sexual and/or physical
abuse and other dissociative disorders
(see review by Bremner, 2010)

• Often not found in primary DDD

samples
• But instead emotional factors:
•Childhood emotional abuse
•Threats, negative statements
•Childhood emotional neglect
•Lack of affection & involvement 8
 Onset of DDD
Four common patterns of onset:
1. Psychological trauma - PTSD and CPTSD
- often seen within trauma services
2. Anxiety – either chronic anxiety or sudden
high anxiety
3. Recreational drugs (usually with adverse
reaction to drug effects and panic attack)
4. Depressive episode (usually slower onset
of DDD)

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Understanding the function of dissociative responses

Dissociation is an innate psychological mechanism to

protect from overwhelming and inescapable affect. Like
a ‘psychological trip switch ’.

Metaphor of a fuse box with components (reality,

emotions, cognitive (including memory), physical, sense
of self) that get switched off - temporarily - to protect the
person
BUT with a lack of understanding about this process, the
symptoms can be very frightening and create a ‘vicious
cycle’ which exacerbates and maintains the symptoms
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CBT is very useful for addressing these patterns
 Updated CBT maintenance formulation
Hunter et al., 2003, Behaviour Research and Therapy

Various external and/or internal triggers

Increased awareness of DDD symptoms

Cognitive biases: Emotional responses:

thinking biases, symptom overwhelmed, anxious, sad,
monitoring, worry, ruminations hopeless, angry
(philosophical)
Catastrophic cognitions about
meaning and consequences of
DDD symptoms

Behavioural responses: Physical responses:

avoidance, checking behaviours, dizziness, numbness,
searching for a ‘cure’, acting adrenaline, fatigue
‘normal’ 11
 CBT-f-DDD Therapy Levels
Level Content

1 Engagement, goal setting and psychoeducation about DDD

2 Developing the shared formulation

3 Cognitive strategies: content & process

4 Emotional regulation strategies

5 Behavioural interventions

6 Working with common co-morbid conditions triggering DDD

7 Working with issues related to onset

8 Working with predisposing factors

9 Staying well plans

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 Evidence Base : CBT for DDD
Hunter et al., 2005, Behaviour Research and Therapy

 Audit of 21 participants from specialist NHS clinic with

primary DDD (17 male)
 Mean age : 38 years (s.d.=12, range 23-74)
 Ethnicity : all were white British/European
 Mean age of onset : 22 years (s.d.= 12, range 5-65)
 Mean duration of DDD: 14 years (s.d. = 12, range = 1-42)
 Mean number of CBT sessions: 13 (s.d.= 6, range = 4-20)

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 Standard questionnaires
• Cambridge Depersonalisation Scale (CDS), Sierra & Berrios,
2000
• 29 items scale assessing DR/DR symptoms with ratings of frequency (0-4) and
duration (1-6) of symptoms over the past 6-month period
• Total score = 290
• Score of >= 70 correlates with clinical diagnosis of DDD
• If want to use pre and post, can change time period to previous month
• Beck Depression Inventory (Beck et al, 1961)
• Beck Anxiety Inventory (Beck et al, 1988)
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 Results

Post- Six-month
Pre-therapy
Clinical measure therapy follow-up Repeated measures ANOVA
mean (S.D.)
mean (S.D.) mean (S.D.)

CDS-State 38.8 (21.8)a 29.9 (22.0)b 26.2 (19.5)c F(2,40) = 11.0***

BAI 21.8 (12.7)a 14.8 (8.8)b 14.7 (11.5)b F(2,40) = 8.6**

BDI 22.3 (10.5)a 14.3 (10.0)b 12.8 (9.9)b F(2,40) = 24.9***

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 Current Audit of Clinical Services
• 36 Participants from specialist CBT for DDD service
• Minimum of 8 sessions
• Three outcomes
• Cambridge Depersonalisation Scale – CDS
• Beck Depression Inventory – BDI
• Beck Anxiety Inventory – BAI
• 3 Time points (Entry, Pre Treatment, Post Treatment)
• Co variables of age ethnicity and gender pre-specified
• Hierarchical analysis of self controlled outcomes to account for intra-person clustering
 Baseline Characteristics of Population
• Mean age 38.7 (range 22-76) SD(13.4)
• 61% Male
• 80% White
33% Unemployed, 13% Professional 11% Skilled
Mean age of onset – 23.8 Years
Mean duration 15 years
80% had at least one comorbid disorder – (GAD, depression, social anxiety,
psychosis, alcohol misuse, PTSD, OCD).
 Change in scores

  Assessment (S.D.) Pre-therapy (S.D.) Post-therapy (S.D.)

CDS-Trait 157.9 (62.4) 153.4 (65.3) 117.5 (69.7)

BDI 27.0 (12.7) 23.0 (9.4) 15.7 (11.4)

BAI 20.6 (11.3) 20.7 (11.5) 15.3 (11.7)

Cambridge Depersonalisation Scale
Beck Anxiety Inventory
Beck Depression Inventory
 Conclusions, limitations and next steps
• CBT may be an effective treatment for DDD.
• However, treatment was not randomly assigned and clinical staff
assessing outcomes were not blinded so bias could account for some
of the results.
• The sample is small.
• More research is needed, including the use of blinding and
randomisation to assess the efficacy of CBT for DDD.
 Feasibility Study
• Discussion with RDS
• Suggested a parallel arm RCT feasibility study
• Feasibility of:
• recruitment,
• retention,
• delivery of therapy,
• pooled standard deviation of the primary outcome at baseline,
• CBT for DDD being delivered by generic NHS therapists with training and ongoing supervision
Feasibility study funded by NIHR RfPB
Ethics and NHS consent obtained
Recruitment just started
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Questions?

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