E131 - What if Nothing Felt Real Anymore? (Depersonalisation & Derealisation w/ Dr. Elaine Hunter)

Dr. Elaine Hunter  is a Consultant Clinical Psychologist who has worked with Depersonalisation and Derealisation Disorder since 1999. She has conducted research into improving psychological treatment of the condition and worked clinically to try to help many people with the condition. 

 In March 2019 she set up The Depersonalisation Clinic to allow her freedom to see a wider range of clients. She is a founding member of Unreal - a charity dedicated to helping individuals with Depersonalisation and Derealisation. In the last few years she has collaborated with many involved with Unreal in trying to raise awareness of DPDR as well as improving access to treatment and increasing research funding. 

You can find out more about Unreal here - https://www.unrealcharity.com/

Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

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Transcript

[00:00:00] Welcome back. What if you woke up one day and nothing felt real, or perhaps you looked in the mirror and felt, even though you recognized yourself, you didn't seem real in some sense, or you felt disconnected from yourself as though you were just running on autopilot? These experiences are more common than you might think.
In fact, they're part of an increasingly recognized phenomena known in the psychological community as depersonalization and derealization. With us today to discuss these experiences is Dr. Elaine Hunter. Elaine is a consultant clinical psychologist who has worked with depersonalization and derealization since 1999.
She has also conducted research into improving the psychological treatment of this condition, and she developed a cognitive behavior approach for depersonalization and derealization in March, 2019. She set up the depersonalization clinic to give her the freedom to see a wider range of clients. [00:01:00] She's one of the founders of Unreal, a charity dedicated to raising awareness of derealization and depersonalization, and improving access to treatment and increasing research funding.
Today we discuss why this condition has been so historically under-recognized, both in clinical settings and in public discourse. Some common misconceptions about derealization and depersonalization. She'd like to dispel common causes and triggers, how her clinic approaches the treatment of this condition.
Why derealization and depersonalization may have an adaptive function in some individuals. How her understanding of this condition has evolved over time and much more. This is the Thinking Mind, a podcast all about psychiatry, psychology, psychotherapy, and related topics. If you'd like to support us, do leave us a rating, a review, follow or subscribe on whatever platform you're listening on.
If you've feel so inclined, you can also share it with a friend. If you'd like to support us [00:02:00] even further, you can check out some of the links and services we offer in the description. As always, thank you for listening. And now here's today's conversation with Dr. Elaine Hunter. Elaine, thank you so much for joining me.
What drew you to work with patients with depersonalization and derealization? Yeah, that's a really good starting question actually. My, my, before I went into a clinical role, I, I actually did a PhD and my PhD was in childhood trauma, a very severe childhood trauma. And during that research, in talking to people about their memories of their trauma, they started describing dissociative experiences.
So they talked about dissociation that might happen spontaneously, sometimes dissociation that started. That they consciously decided to use as a way of sort of mentally escaping from what was happening to them. [00:03:00] And that really fascinated me. It was something, it was a little bit unexpected in the PhD. I was looking at memory and then people were talking about dissociation.
And so when I finished my PhD and I was looking for a kind of post-doctoral position, it just coincided with the depersonalization derealization research unit as it was then being set up at the Institute of Psychiatry. So I kind of thought, oh, that sounds really interesting and applied and then ended up working there.
And so that's how I got into it initially and then started looking more at at dissociation. And is there a lot of overlap between dissociation and the utilization? Depersonalization? Are they, in your view, like distinct phenomena? Is there a gray area in between? Yeah. Again, a really good question.
Generally they overlap enormously. A long time ago we kind of dissected the kind of overlap and we found out that about [00:04:00] 75% of people will have both depersonalization and derealization. There were about 20% that had depersonalized own depersonalization only and about 5% with derealization. But actually I am finding a few more people with just the derealization only, but often, so technically there are two separate things and that probably leads on to the next question about what are the symptoms.
Uh, technically they are two distinct things and people can have one or the other, but as in the, the latest. Iteration of the DSM, uh, you know, the di the American Diagnostic Manual, they've actually pulled them together now, so they tend to be called derealization dash de uh, depersonalization dash Derealization disorder.
So they've kind of recognized that and merged them together. And you were totally right about what my next question is gonna be. My next question is, you know, what are the symptoms and signs that [00:05:00] someone is experiencing something like idealization depersonalization? I, I would say from the outset, this is gonna be on the rare side of things.
So I imagine it's something you could correct me if I'm wrong, that a lot of people might experience idiosyncratically without ever realizing they have a kind of diagnosable condition. What are the signs of this condition? So the key thing that makes it distinct from any other kind of condition is this sense of, uh, unreality so, and disconnection from the world.
So the unreality is that sometimes for the depersonalization, so that's the bit that relates to the person and derealization is referring to the outside world. And as I say, usually the two are interacting with each other, but it's a sense that there's something not real about the person themselves.
They don't really feel real like they properly exist. [00:06:00] And the outside world can seem unreal, like a stage set. So that's one aspect of it. It's actually got quite a few different essential criteria. So one is this set of sense of unreality. The other thing that people quite often describe is a sense of disconnection.
So they may be disconnected from parts of themselves. If you, if you look at the kind of diagnostic criteria for dissociation, it talks about how all these functions that are normally integrated, like a sense of self and memory, uh, and identity and a sense of reality, are all kind of part of usually connected and integrated with each other.
But sometimes things, things can feel un uh, disconnected, unconnected from each other, and emotions as well as another one. So people can feel like they're disconnected from their emotions. So people can also feel a bit sort of removed from them, their own [00:07:00] body as well. So. Unreality sense of disconnection, feeling like things are a bit dreamlike is another key one.
So sometimes people will say that they don't really feel like they're really in the world, that sort of, not really in reality, they kind of feel like everything feels really dreamlike and a loss of kind of consequences of their actions. So those, what I would say are the, the essential criteria that make depersonalization and derealization, you know, that distinguish it from any other disorder.
And those are very common, but the in, in a transient state. So people will often have just momentary times where they might feel a bit spaced out, a bit disconnected, um, with lots of very common benign triggers to that. But for people that have the [00:08:00] disorder, that has become much more problematic associated with distress.
You know, it's sort of reoccurring and or constant. So there's, it's a very, very common symptom. But also I would argue that the disorder is a lot more common than is previously thought. So I wanna scrub out that rare, when you said that I wrote that down, I want you to come back to it because it's not as rare as people think when you do the kind of epidemiological surveys, it's surprisingly common.
Excellent. Well, one of the things this podcast is for is for me to be proven wrong. So very happy to be corrected. So you're saying. Derealization depersonalization. There is experiences of unreality. The experience itself is very common in a limited way and can have various benign causes, which I'll be interested in.
But to have the disorder, it's the same problem. But having but happening in a more constant, [00:09:00] pervasive way. Is there a sort of determined set of time you have to be experiencing this to meet the, the criteria for the diagnosis? Yes. So it tends to be, it can be that it's coming in episodes, so you can have a, you know, a, an episode.
So, yeah, so, and that can vary, but it, it's more that it's, it's associated with distress and, and impaired functioning as well. So, yeah. Uh, and different, you know, there's different diagnostic criteria, but generally it's going to be, you know, coming for significant periods of time. But then there's some people that are also experiencing it chronically, but that can vary in intensity.
So, you know, they may have all the time, but it may go down to 10% or it might go up to, you know, fluctuating up to, I know 90%. So those are things when I'm assessing people, I'm, I'm also looking at the pattern of their [00:10:00] depersonalization, derealization. I am curious to know how common it is, and I'm also wondering, is part of the reason that it's perceived as rare, is that because it's under reported?
'cause as I said before, I would imagine that it's the kind of phenomena, this sense of unreality that if you experience it, you might not automatically think you're suffering from a mental health condition. I imagine a lot of people might think. That they're having a spiritual experience or something along those lines.
But again, you could correct me if I'm wrong about that potentially, but though, but people that interpret the symptoms in that way, usually that aren't distressed about it. Yes, that makes sense. Whereas people that are distressed about it are interpreting those symptoms in a fearful way. And can these symptoms ever be brought on by a spiritual practice, such as meditation or even going on a silent retreat and, and that kind of, [00:11:00] uh, sense of being con continually alone with your mind and your psychological reality for a long time inducing that kind of experience?
As a scientist, I have to say yes, that is possible, but I would really want to emphasize how incredibly unusual that would be. Okay. So I don't want people kind of thinking, oh, you know, I can't do meditation, or I can't go on a retreat. Because I would, when I, when we talk a bit later on about some of the common triggers, I don't know if I've ever heard that.
Okay. Or if somebody has attributed, I can think of one person and literally, you know, a thousand plus people that I've kind of assessed. So, you know, it's a very tiny percentage. But actually they were also experiencing lots of other difficulties at the time, which kind of made them go on a, on a very intense retreat.
So it's kind of like, you know, was it that they were leading to that anyway, rather than the [00:12:00] retreat itself. So, you know, there, there is somebody who's done some work about how, you know, just warning of some of the dangers of retreats and meditation, et cetera. But I think they're talking about people that are doing quite extreme versions of that.
So it's, it's not, it's not, it's not a trigger that I see commonly in the clinic at all. Okay, so how common is the disorder? So the disorder in, in normal populations, when I say that nonclinical populations, I'm meaning, so we've done two reviews of surveys that have been done in kind of community samples to see how common the disorder is.
Um, and you might be, and one was done a long time ago and one was recently updated and both have been published and this sort of magical 1% seems to come out. So this is of clinically significant level of symptoms. [00:13:00] Uh, 1% of people, when you go into the community and ask people about these experiences and ask them about, you know, how much they're having them, how distressed, how impaired they are, yeah.
1% of the population is, is experiencing it, which is really surprising. That is the sort of. Same level as something like OCD, the same level as sort of schizophrenia. I don't particularly like that terminology, but that's the kind of same level. And that's been done, you know, through repeated, uh, surveys. Um, and actually globally.
So the last review, you know, we were looking at different epidemiological surveys around the world. Now when you move into clinical populations where people have, you know, anxiety, depression, or something else that's already causing distress, those numbers go up a lot higher. Um, and then when you look at something like, sorry, [00:14:00] when you look at something like panic, the numbers are up in the kind of 80 percents.
Oh. So it's very commonly associated with panic attacks. Very, very permanent, commonly associated with panic. In fact, if you know your panic diagnosis. You'll know that depersonalization and derealization are two of the symptoms of a panic attack. Yeah, and I was just thinking it's kind of a chicken and egg problem.
'cause I can imagine panic inducing, a derealization depersonalization experience. I can also imagine such experiences causing significant anxiety and panic. Yeah, and that's exactly where I kind of started to, you know, develop the kind of, what is now the kind of CBT model of depersonalization derealization.
It's kind of, you know, was really seeing panic attacks coming up again and again and again. Understanding. Well, you know, there are some people where they'll have. A panic attack, they might [00:15:00] experience the depersonalization derealization as part of their symptom cluster of a panic attack. But as the panic start starts to, to subside, those symptoms dissipate.
So you know, they go back to, you know, how they were before, but with some people they will then maintain some level of depersonalization, derealization. So part of what I needed to understand and explain was why that might happen. And it's almost like the anxiety about those symptoms then becomes a perpetuating factor and it kind of then kind of keeps fueling the fear for this.
So it's like the anxiety then attaches to those symptoms and they the Yeah. And then the anxiety kind of keeps the problem going and it becomes a positive feedback loop. Exactly. So you end up with this kind of vicious cycle [00:16:00] where, so sometimes people will say they still have panic attacks, but sometimes people will say, no.
The panic, I don't have panic now. I just have depersonalization, derealization. But it's like the anxiety about what we, you know, the other physical symptoms of anxie of panic and anxiety has now landed on these depersonalization derealization symptoms and they're very frightened of them. There's often a lot of anxiety and distress about these symptoms, which is completely understandable because they do seem very frightening if you dunno what they are.
And again, I'm hung up on this question. For some reason I'm imagining someone experiencing this for the first time. Do people in your experience know what to do? Do they tend to go to a and e? Do they tend to go to their gps? Do they? Is is, are people familiar enough with these terms now that they might Google it and, and find professionals such as yourself?
Do [00:17:00] people have to take a long circuitous route to kind of finding the right diagnosis and the right treatment? Yes, to all of the above, really. Um, uh, it's a lot better than it used to be. 'cause I started working in this area about 25 years ago, and at that point there was almost no information about it.
So people were, uh, had no initial awareness, or if they did experience symptoms, there was no way of getting information about what the symptoms were. Whereas nowadays, people can, you know, Google the symptoms and, you know, get information about. What these symptoms mean. So if you've typed in something, I haven't done it myself, but if you type in something like, you know, not feeling real or the world not feeling real, it will just pop up immediately with, you know what, this is the next step of trying to then get help for it is still a bit problematic.
And also we've been working on that for, you know, the [00:18:00] same number of decades. It's, and, and again, I do think it's a lot, lot better. So I do hear people now that, you know, go to their gps and the gps immediately know what they're talking about and are able to help them. And, you know, similarly, other mental health professionals, you know, they're able to kind of go and get help.
That, that is much, much better. But it's still very, very patchy, unfortunately. So we are really pushing always to try and raise awareness. That's why I'm talking to you today. And what, what are the common. Triggers and causes for this condition? Well, that's in, in really developed over the, the, in the time that I've been working with it because initially as I say, my background was in trauma.
Um, and so I came in thinking, oh, you know, there'll be lots and lots of people that will have had traumatic experiences and that's how they've developed these symptoms. And then I was very puzzled that I [00:19:00] wasn't seeing people with traumatic histories in the depersonalization research clinic. I was seeing people usually that had a lot of anxiety problems.
So just going back to the trauma, people can have trauma and trauma is a really big trigger for dissociation. I mean, there's plenty of clinical and research evidence for that They will tend to then go off to, 'cause they'll know that they've had trauma and they'll tend to go off. To seek help and you know, they'll disclose that they've had trauma and they'll go off to trauma clinics and get trauma treatment.
So it's not, that isn't a trigger, but there are a lot of people. And so one of the misperceptions is that it's got to be trauma related. And actually going back to what I was saying earlier about there is strong association with panic and how depersonalization and derealization are two of the symptoms can be of a panic attack.
There's a [00:20:00] really strong association between these experiences and extreme anxiety. So one of the big areas is people that have had sometimes a long history of anxiety that's just accumulated and just grown over time. So they might have had, you know, sort of childhood anxiety and then they've developed more and more anxiety, maybe leading into panic attacks.
Uh, but it can be other types of anxiety as well. Uh, just very high levels of anxiety and they start becoming really overwhelmed and then they start disconnecting from the anxiety or somebody who, you know, has experiencing a panic attack. And then, you know, that very acute level of anxiety, they suddenly start feeling really unreal.
So that's one of the, so we've got trauma and anxiety. The other two, well the, there's two other main categories. [00:21:00] Another one that I see a lot of is people that. Attribute it to some sort of substance use. Uh, usually recreational substance use, where they'll kind of say that, you know, in the context of taking substances, sometimes one, sometimes they might have taken a few substances, they have a really horrible experience under drugs.
Um, and in the context of that sort of bad trip kind of experience, they might also feel, um, some depersonalization, some derealization. But critically they usually have a panic attack at the same time, you know, in that kind of bad trip experience, when you really assess it carefully, they've often kind of then describe, you know, feeling really panicky, really out of control.
And I would say that's the common denominator. So some, they will then sometimes think, oh, it's the drugs, but [00:22:00] the drugs then wear off that they're then having this, you know, really fearful kind of reminders of this experience. And again, that's anxiety is then attached itself to this kind of sense of reality.
And then they're kind of checking in, oh, I'm, I still having that weird sort of sense of not being here, not being real. Things looking weird, feeling weird, feeling outta my body a bit. And then that sort of starts snowballing from there. And when you mentioned drugs, the first drug I thought of was ketamine, where the effect of the drug itself, ketamine is a dissociative.
Really the, the drug, the, the effect that the drug tends to have. Sounds a lot like ization, depersonalization to me. So is ketamine a very common trigger in terms of drugs? You are right. 'cause ketamine is actually being used experimentally to induce the symptoms of depersonalization derealization. So you're absolutely [00:23:00] right.
Mm-hmm. But sometimes, but I think people that are taking ketamine will kind of then know this is what I'm expecting from the ketin. So it's a, it's a feature not a bug. And that's a situation. Exactly. So it's always, you know, a bad drug experience. So, you know, and, and what's really crucial is that, you know, when I'm carefully assessing people, I'm, I'm keeping my, you know, I'm looking to see, have they taken those drugs before?
And often people have taken the drugs, you know, before and, and it's been absolutely fine. And then suddenly they have a bad experience. So there's usually other factors involved. So I, I'm probably unusual, but I, I feel it's because I am, I've really looked at this in a lot of detail in, in hundreds and hundreds of assessments, is that people usually will come in and feeling really like, oh my God, why did I do those drugs?
And it's really [00:24:00] caused this problem. And I do a very careful assessment so that I can often then say to them, can you see, actually it probably wasn't the drugs. You've taken the drugs before. You were fine before, but this time you took them for certain, you know, other reasons. You know, you had a really bad experience on the drugs.
You had a panic attack. You know, this kind of then caused it to snowball. And that you are probably unfairly blaming yourself for taking the drugs or take, you know, blaming the drugs themselves in some way. And I say that because I think people can really get caught up in that and it affects sometimes their help seeking because they kind of feel like, I don't want to go and talk to someone about it, because they'll just say, well, why did you take these drugs?
But also it's really important to kind of see that the, that there are, you know, there are other causes and usually it's the anxiety or the panic attack or the bad experience that they've then [00:25:00] developed almost like a, a kind of PTSD reaction to that bad drug experience and then have become, you phobic almost of these depersonalization derealization symptoms.
I really like that you make, make that distinction because I think when it comes to recreational drugs. Especially, I think, psychedelics, cannabis among adolescents parents, there's often this fear that like one instance of drug use can kind of change your brain in some irrevocable way, and you're forever changed.
And there's probably small amounts of cases where, you know, psychosis might happen, although in all likelihood they would have had a genetic predisposition for that. Generally speaking, this is really rare. We don't, it's very uncommon to see a single instance of drug use or even a few instances like changing someone at a biological level.
What you're saying is actually it's catalyze something that's now persisting more at the [00:26:00] psychological level in terms of inducing anxiety, anxiety. Inducing the, the sense of unreality and that positive feed feedback loop we described earlier? Yes. Well, of course I'm biased to being a psychologist, so I will, you know, obviously be promoting a psychological explanation for it.
But also, you know, actually for about eight years in my career, I worked for a specialist CBT for psychosis service. So I worked exclusively with psychosis for about eight, eight years. And I know that actually, you know, again, that kind of drug, you know, our drugs, uh, a trigger for psychosis and generally people will say, you know, it needs to be certain circumstances, you know, very young taking of drugs and, you know, you, you, you know, lots, uh, uh, you know, very large amounts.
And again, you know, so I think there is now sort of evidence, but you know, that's, it's not usually a sort of one-off. And, you know, I don't know of [00:27:00] any. Evidence for any brain level change from, you know, something like a one-off episode, you know, episode of taking cannabis. So people, no, people often fear that.
And so it's a really common thing that I will encounter with people that attribute the onset to their symptoms to drug use, that I've damaged my brain in some way. And because the symptoms can be very frightening, can seem really, you know, unusual people often kind of really frightened about what they mean.
They often feel like they've, this is it, they've kind of lost touch with reality. Isn't this what going mad is, is this what schizophrenia is? Uh, isn't that, you know, losing touch with reality? So you can imagine what that would feel like, especially as you're saying for a teenager, I. That's kind of suddenly thinking, oh my God, I've, I've damaged my brain in some way, or I'm developing [00:28:00] psychosis, you know, what am I gonna do?
Maybe I, you know, just try and sit this out, hope it gets better. But, you know, they actually then maybe don't seek help to get actually a different take on it and actually be reassured by that. And so, sadly, I have heard quite a few people that, you know, have literally gone for years of their teenager years, just not ever telling anyone because they were frightened about how people would react.
Uh, and do we have any idea of what might be happening at the neurobiological level when someone is having an experience like this? I mean, I'm probably not the best person to ask. I mean, I have worked with lots of teams of psychiatrists that have looked at this, uh, and so you might be better off talking to somebody else that, but I mean.
My, my take on it is that usually they haven't been able to find [00:29:00] anything very substantial. So when the depersonalization research unit was first set up, there was an MRI scanner that had just arrived at the in of psychiatry. So everyone was routinely getting MRIs and having a look at structural and functional MRIs, and basically they, they weren't able to really find anything at all.
Yeah. Which is very common in all sorts of conditions. Of course. Yes. So, you know, we could kind of then say we can't find anything, a kind of brain structural or brain functional, uh, level. Mm-hmm. I would be curious if, again, it's induced any kind of effects, maybe similar to me, meditative experiences, something to do with the default network, perhaps the reticular activation system.
But that's just my totally to the uneducated speculation at this point. Once someone's at, at the clinic, you know, they've had an assessment and it's pretty clear this [00:30:00] is what's going on. They're experiencing de personalization, derealization. How do we start to think about treatment? Yeah, so I usually start with a pretty thorough assessment.
Actually not, I will go into quite a lot about the onset, but I also, because of my background in sort of particularly sort of childhood trauma, uh, I will also want to get a very thorough assessment of all their kind of childhood experiences and everything that's led up to that, because that's often where some of the threads might be kind of leading back to.
And then you can really start to put together. A sort of shared formulation and a shared understanding so people can kind of see what has led to these symptoms starting. What are the most crucial things you're looking out for in an assessment? So it would be, I would be looking for, you know, childhood trauma or childhood [00:31:00] adversity that might be leading someone to kind of feel often with anxiety, um, but also kind of, you know, being in a stressful situation.
So maybe, you know, it's sort of childhood adversity, you know, like an a parent's arguing, et cetera. Just so that that is understandable about how they might have reacted as a child. So sometimes people will be able to kind of say, do you know what, I remember having this as a child very occasionally, but just very transiently.
So sometimes it is, you can find that there are early experiences before it became problematic. I would say that's generally not the case. Most people have not experienced it, but usually I'm looking out for different psychological vulnerabilities from their, their life experiences and also just getting a sense of their personality and their character [00:32:00] before, again, these symptoms started.
But certainly childhood anxiety I will be looking out for. I also haven't mentioned depression because depression is also, will kind of feed depersonalization and derealization. I would say it's less of a kind of, um, obvious trigger. Um, but certainly it can be a trigger in some cases. So there's one client that I assessed described it in a very eloquent way.
She kind of said, you know, I was really depressed and I, I I just didn't want to be me anymore. So she kind of like disconnected from her sense of self and you could kind of see that the depression can also lead to this sort of disconnection from self and the world perhaps. You know, and, and we know that depression and anxiety are very closely, you know, it's harder, one without the other.
And I was curious as well, is there any evidence that psychiatric drugs [00:33:00] can induce derealization depersonalization, like antidepressants, antipsychotics, mood stabilizers? Yeah, I wouldn't say that they kind of induce it. I mean, I wouldn't say that is generally a trigger because we always need to think, well why is that person taking the anti antidepressant or the, the medication?
So there's usually something that's led to them taking this, but certainly some antidepressants will, um. That's what they're there for, will muffle those extreme emotions. So I was literally talking to a client yesterday who's on an antidepressant and quite a high dose of it. And she was put on that because she had, you know, very high levels of anxiety, was really struggling to function and also depersonalization derealization, and it was to help minimize those negative emotions.
But she's now recognizing at [00:34:00] this high level of antidepressant that she's, she can't also experience positive things. She's just started her first ever job and she kind of wanted to feel kind of excited about it and realize actually I don't really can't feel, feel excitement. I feel disconnected from it.
So yeah, I mean, so at that level they're kind of modifying the peaks of emotions, both sort of positive and negative. That's what they're doing their job in that. I wouldn't say that they would sort of, so it can make someone feel a little bit, uh, numb from their extreme emotions, but I wouldn't say it's really triggering this very kind of strong, profound disconnection from themselves.
As a general rule. Again, it is a possibility, but usually people are being put, you know, I'm always a little bit, you know, people have been put on those for a reason, and if you track, I'm a bit obsessive about, you know, chronology of people's [00:35:00] histories and, you know, being a sort of detective in that and kind of thing.
Well, look, you had, that's why that happened. And then that happened, and then that happened. And really trying to piece the chronology together because I think detective wise, that really helps in working out what came first. But, uh, so just before, before we dive into treatment, uh, I am curious as well, if any medical conditions need to be excluded.
Anecdotally, I've had low testosterone actually can cause people to see the world in quite a flat, uninteresting two dimensional way. Perhaps some overlap there. I'm thinking about thyroid problems as well. Now, I, now these kinds of things are gonna present with physical problems as well. So if someone's low on testosterone, they, they might have low libido, say low energy.
Similarly, someone with a thyroid, uh, issue would have low energy, a lot of appetite, sleeping more, all sorts of physical symptoms. But do, do you see this much? Do you ever have to get the GP [00:36:00] on board, do some blood tests, make sure there's, there isn't anything physical going on? The people that I've, that I've, I'm seeing will have already been through all that process.
So, so yes. So no, I haven't seen anyone with. With those, uh, similarly things like, you know, uh, some types of epilepsy or, you know, if it's kind of caused by something that is quite transient and temporary. So a g someone may go to see their GP and it's, and it's, you know, they will do some watchful waiting, you know, okay, this is what this is.
Let's see, you know, you're in a difficult situation at the moment. Let's see how that pans out. And actually that may just alleviate it. So usually I'm seeing people when it has become a disorder and it's actually become a bit more, you know, entrenched and problematic. And so how do we begin to help people disentangle these problems and, and deal with, deal with them in a more [00:37:00] manageable way?
Yeah, so after the assessment, as I start to kinda move into treatment there, there's then a sort of phase of more detailed assessment to just really. Kind of start to see what, what is causing their fluctuation. So one of the first things that I'll usually do with just about everyone actually, unless they really, really don't want to do it, is actually get them to keep it quite a detailed diary.
It's just a one-off, but just a detailed diary to look at what kind of things might be causing some fluctuations in symptoms. So if people are saying, well, you know, I think they go from about a 30% to 70%, we wanna kind of see what's, what's triggering the high, the peaks. So I'll get people usually for a week or maybe two weeks to just track the sort of percentage of symptoms and what they're doing so that we can start to see the association and that's [00:38:00] making, um, these kind of common patterns of things that might make it more difficult, uh, make the symptoms worse for people.
We're individualizing that. So usually when people are in more stressful situations, the symptoms will get worse, but what's stressful for you might not be stressful for someone else. So I need to kind of check that out. And that often might bring up other areas like, you know, social situations that they might be in cause you know, really triggers off their, their depersonalization derealization and gives other clues or that they've got kind of low mood that's also attributing or anxiety or whatever.
So that's helps us to kind of see what areas we need to target. And in addition to that, I will also usually do a kind of a very typical kind of CBT vicious cycle. Maintenance formulation. That's all very jargony. But basically [00:39:00] just finding a time. So if Alex, you'd give me a diary of, you know, there were a couple of times where your symptoms were really bad, I'd map with you and literally map out on paper what, let's have a look at one of these typical times where your symptoms get worse and we'll look at what the trigger is, what symptoms you noticed crucially at the center of it.
What was, what were the thoughts and what were the beliefs and attributions that were happening? And then what were your emotional responses, your behavioral responses, your physiological responses. And also I map out and a sort of additional bit, which is your kind of thinking, sort of cognitive processes as well as cognitive.
Content. So cognitive content, I'm actually thinking of, you know, capturing the verbatim thoughts that might be going through your mind, but there might be other processes [00:40:00] as well, such as, you know, symptom monitoring or putting your attention on it, or particular kind of thinking biases that might be attached.
So we would then map out a typical pattern. We may layer on another one that's a different situation, different trigger, so that we've got, you know, sometimes just one, sometimes two or three that are overlapping each other and really that is telling us what do we need to start working on. Um, and that usually leads into looking at your thoughts about these symptoms and what's happening about them.
So often in the assessment I may have asked people, you know, when you first experienced these symptoms, what kind of, what did you make of them? What did you think was happening to you? And some of those really very frightening beliefs may still be residual. Now they might not be that residual. They might be [00:41:00] really quite prominent still, you know, I've damaged my brain in some way, or, you know, um, I'm going crazy.
Is this the beginning signs of schizophrenia? You know, I'm never gonna get over this. You know, sometimes people have gone on the internet, which is, you know, is very helpful for information giving. But al also, you can read about people that have had this for long periods of time and that can be very frightening for people to read about.
Or they real, they read that there's no treatment or. Things like that. So there can be a lot of very frightening, uh, beliefs about the thoughts or, or also how it might be affecting their functioning. So it might be other people can see this and they can see that I'm disconnected or what other people are gonna think of me or a whole bunch of kind of cognition.
So what I'm trying to do is extract those unhelpful beliefs about the depersonalization, [00:42:00] derealization symptoms and also then map out their responses to that both, you know, with maybe behaviorally, we usually looking at different avoidances or they might be things that they try and do that they think might be helping, but actually might be maintaining or making things potentially worse for them.
So that's kind of where we would start in the treatment. And then moving on from that is, if I haven't done it already in the assessment, sometimes at the end of the assessment we'll really look at what is, what is depersonalization, derealization, what is the theory behind it? What is actually happening to people?
And that's really helping people to see that this is dissociation. Generally in depersonalization. Derealization being two types of dissociation are actually, you know, an incredibly interesting and clever way that humans have of just taking themselves, removing [00:43:00] themselves. From a situation that feels really overwhelming and inescapable.
So if you can't run away, you then can dissociate and hence, you know, that's why I was, I was finding it in people with childhood trauma. They couldn't get up and leave home or get away from the trauma that they were experiencing. So they learn to kind of psychologically remove themselves. I say learnt in some cases, but sometimes it will spontaneously happen in a dissociation.
We just happen, we, it seems to be a really innate human mechanism to kind of just take ourselves away from this situation. So one thing that's really crucial in the treatment is for people to, to see that it's actually a kind of benign, a trying to be helpful mechanism. That has become, but you know, if you don't know that, and most people [00:44:00] don't, when it first happens to them, you kind of get really frightened that you are, you know, disconnected or you're losing kind of parts of yourself.
So it's really helping people to see, you know, they're sort of more psychological, theoretical perspective on dissociation is trying to help you, your mind is trying to help you here, and therefore reducing the fear of these symptoms that have become a bit stuck so often. You know, when people lose the fear of the symptoms, they start to dissipate because they're not being maintained by anxiety.
That's kind of like the fuel that's keeping them going. And I think this lens is so useful. I. To take for other mental health problems like depression and anxiety. I think you can make a strong argument in many cases that that's also your brain trying to help you, like at least [00:45:00] sadness or some element of depression is, for example, helping you, taking yourself out of a stressful situation, maybe thinking about some losses you've had and why they're important to you.
Anxiety is there really to help keep us safe and to avoid threats. Yes. You know, anxiety can misfire and we become, we can become anxious about things which aren't really posing danger to us, but the reason like anxiety, sadness, anger, even these things all exist for good reasons. And then as you say, we can get into these vicious cycles where our reactions to them.
Can make them worse and worse and it can kind of spiral out of control. Exactly. So that's what I'm sort of mapping with somebody in a sort of shared way. We're both as a team trying to, you know, pinpoint in know times where these symptoms are, are very, uh, prevalent and being triggered to work out well what's, what's happening in that scenario?
You know, how are you reacting to that so that we can then start [00:46:00] to dismantle those kind of feedback loops. Um, and you know, bit by bit stop that kind of snowballing effect. Putting sort of, I'm mixing my metaphors here, but putting breaks on in different places so that, you know, these feedback loops aren't happening so that we can start to create what we'd call a virtuous cycle where, you know, the symptoms may be triggered, but we kind of go, oh, okay, this is what's happening.
You know, what's going on? What, what's causing this to happen and how can I change? Situation in some way, or how can I change, you know, what I'm thinking about the situation that will be more helpful to me. So, but there are certainly some people where the depersonalization and derealization has become quite a habit for them.
Um, and they may have had it for quite a long time. Um, and so, uh, there are people where, so most people, initially, there's quite a [00:47:00] lot of stuff that's maintaining the depersonalization, anxiety, depression, all sorts of things. So, uh, I'm looking to see what is causing these symptoms, the dis what's causing the dissociation, and then alleviating the causes that's keeping it going.
Also alleviating the anxiety about the depersonalization derealization, and then if, if there's still residual symptoms looking at this. Being a bit more of a kind of default habit that they've, you know, developed as a way of kind of just sort of disengaging from, you know, life. And sometimes that can be a little bit more of a kind of, um, you know, a way of intellectualizing life, sort of standing back from it a bit.
So sometimes it's, it's become a little bit more of a sort of personality trait to kind of be a little bit more, to be detached. Yeah, to be detached. [00:48:00] So, you know, the, uh, in terms of the kind of treatment, I usually start with kind of CBT because there's usually a lot of mileage in that. But I may bring in, if it's, if the CBT on its own is not sufficient, I may bring in other ways of looking at things that are a bit more, so I would use something that's called schema therapy, which is a bit more looking at more.
Schemas or traits. Um, and in schema therapy there's a, it's in the kind of model itself, which is called the detached protector mode, which is basically describing, you know, someone that's sort of detached as a, as a form of protecting themselves from emotions. And you said sometimes people can do things to try and help and to try and like decrease these experiences, but they end up maintaining them or making them worse.
What are the common behaviors that people do which make things worse in number one would be [00:49:00] avoidance. Like avoidance of stress. Yep. Or situations that trigger stress, you know, so yeah. So they may, uh, withdraw. So, you know, I sometimes get people that have, you know, just literally gone into their room for months.
Um, and some people are working with a couple of people at the moment that have become completely acrophobic. They've just haven't gone out for, for years. So, you know, they're, they're, because they're so, it's because they're frightened of the depersonalization derealization being triggered. And that's what that is causing the agoraphobia mixed with some, you know, anxiety and panic, but it's more focused on, on those symptoms.
Um, but it can also be social situations. Um, yeah. And, but also what in, uh, CBT terms is called safety seeking behaviors, that people as well as maybe avoiding things may do things that they [00:50:00] think, you know, helps prevent the symptoms come. And so, so those, they can get kind of entangled with, you know, doing certain things that actually they think helps prevent this or prevent it getting worse.
And so we need to kind of test that out experimentally. So that they gradually let go of that. So gradually, so I'm, I do, you know, like graded exposure and behavioral experiments so that they can test these beliefs out, test things out, and gradually start introducing things back again. Or alternatively start dropping things that they've, you know, props that they've got, you know, starting, you know, that they clinging on to.
So that's the kind of most common things in a, in a kind of on the behavioral bit of the CBT, I'm enjoying listening to your way of working. It's making me think about CBT generally as it applies to anxiety, depression, what have you. CBT, cognitive behavior therapy [00:51:00] includes talking about thought patterns, emotional patterns, behavior patterns.
I feel like very often we misperception like how we see the world. So imagine someone who doesn't have de realization, depersonalization, they just have social anxiety, for example. I feel like a lot of times when we're treating people with social anxiety, say we miss the fact that social anxiety isn't just a way of behaving or feeling or thinking.
It's also a way of perceiving the world. So like an example I'll use commonly someone with social anxiety will walk into a party, say, see a group of people laughing. They're much more likely to perceive that group of people to be laughing at them. That's their perception that's kind of matching their psychological state.
So I'm enjoying listening to talk about your way of working. 'cause obviously derealization, um, depersonalization, those are perceptions. So you're forced to actually look at how is this person's psychology [00:52:00] affecting the way they're perceiving the world? And I wish we did that more when it came to depression, when it came to anxiety and, and, and other conditions as well.
Well, is there, I mean, I, as I say, I kind of will have. CBT, you know, the way people map it out, they might do just a few different kind of boxes that you put things in, but I, and I, I always include, now, as I said earlier, a difference between the kind of cognitive content as I call it, your kind of a verbatim thoughts that you might have, but also these cognitive processes.
So in the cognitive process section is stuff about kind of thinking biases and attentional biases, which is what you're talking about. You know, you go into a room, where's your attention going? It's, you know, and, and so with depersonalization derealization, there's often a lot of kind of. Self-focused attention, very similar to kind of social anxiety.
They'll be [00:53:00] kind of really checking in with their symptoms all the time or temperature taking. So you've got your little kind of depersonalization, derealization, thermometer, metaphorical that you're just, how is it now and what's it like now? And just constantly checking your symptoms. And so, you know, most people will kind of go, oh yes, I do that a lot.
And in checking it, you then become aware of it. You kind of then, you know, catastrophizes part of the thinking biases again, there's more thoughts. Oh my goodness, it's getting worse, you know, now people really are gonna notice I look weird, you know, I look glazed over or whatever. And, and so it's, it's a big part looking at the attentional and thinking biases part as well, because that's another area that you can target therapeutically.
And you said once people become aware of these patterns and particularly once the fear of the experiences comes down, then it tends to [00:54:00] dissipate. So is the prognosis quite good? Like if you get the right diagnosis and you engage with treatment prognostically, is it quite optimistic? Yes. And ideally, the sooner that that happens, the better before it becomes entrenched.
Yeah, and the problem is, and I, I literally, you know, yesterday with a client was she was talking about how, you know, unfortunately going and speaking to people that didn't know very much about depersonalization, derealization just left her feeling, you know, oh my goodness, what is this? And you know, she was saying, you know, like you would with a physical condition, if you go and seek help and you, you are surrounded by people that go, wow, I don't really know what this is or what we do, you would be, you know, really getting quite worried.
The doctors dunno what this is or what they can do about it. And everyone seems a bit baffled and lost, you know, and that really can just feed that anxiety. [00:55:00] So yeah, we really need to try and get help there and we've tried to do it through Target, a targeted sort of what it is and what you can do to help targeted at gps.
And then we've got, you know, Royal College of Psychiatry. We've got an online module about this. So really getting people to be able to know what it is so that, and then, you know, have some basics of what is helpful for people so that very early on when people seek help, they can be reassured. We know what it is, you know, there are treatments available because there is still this kind of like, we don't really know what to do with it.
Uh, which is a bit unacceptable now because there is evidence that. Certainly antidepressants as well can be helpful for people. Um, but also, you know, talking therapies and this all I've done really is, you know, apply the CBT templates to this [00:56:00] condition. So you know how my work might differ from general CBT is only that I'm putting all of this at the kind of heart of the CBT model, but people, you know, can get help with their anxiety or depression that may then also alleviate their depersonalization and derealization as well.
Yes, and it sounds like there's a lot people can learn even if they don't have a mental health condition about just understanding your mental habits and patterns, understanding how they help you, but how that coping mechanism often serves to undermine our best interests. I feel like that's something I wish more people.
Understood. Like we only, we usually think of habits as behaviors, things I do over time and I really wish people would understand that a way of thinking and feeling is also a habit. It's just one that kind of starts automatically as we go through life and get older. But it's [00:57:00] also, uh, CBT reveals this something we can have some watership over and, and often the things we think we're doing, which are going to help us and we really, they're often our most steadfast allies we think can be causing us to stagnate and stopping us from moving forward at times.
Yeah, I mean I'd like ideally it to be the level of awareness so that people know what kind of dissociative phenomenon are before they experience them, because then you kind of go, oh, right, I know what this is. This is fascinating really, you know, as well as, you know, I'm being obviously in a difficult situation, but.
Wow, you know, this is what's happened. I know what it is. Therefore, I don't need to be frightened a bit because they don't have that. People are often quite frightened of dissociative reactions, but for most people they can be just transient and helpful. What do you think has surprised you the most over your years learning about and [00:58:00] working with this condition?
Or what, what's the biggest thing you've changed your mind on? That's an interesting question, I suppose. What has fa Well, I originally started thinking it was just all about trauma and then being puzzled as to why are these these people coming and seeing me and they don't seem to have any trauma. So that, but I learned that quite quickly about whether it's not just trauma that causes this, but I suppose sort of as you get to see more people, there can be sort of other subgroups and there are people as well where they would say that they don't feel very much anxiety.
So this is a kind of newer realization in a way for me, is that there are people who, there's a sort of a perfectionistic, uh, or people with perfectionism subgroup, and that's the kind of pressure and the sense of being overwhelmed by their continual, unrelenting [00:59:00] demands on themselves that seem to be maintaining the depersonalization.
They'll sometimes say, I don't really feel anxious, but wow, I do need to get on with all this stuff. And it's really unrelenting and impossible to achieve. And so there's a sort of depersonalization that seems to be, um, maintained from some people that have very, very high levels of, uh, expectations on themselves.
And that I don't think has been really written about or, or, um, yeah, it's in the sort of professional or public realm very much. I've been thinking a lot about perfectionism and over achievers on the podcast. I've written a couple of essays about it. I didn't know that this was also something they could experience.
Actually. Very helpful for me to know that. Are, are there any online resources or books you would recommend if someone wanted to go deeper and learn more about depersonalization Derealization? Yes. I would say it's very good [01:00:00] to make contact with the charity, so myself and it's, I was kind of part of it initially set up a charity specifically for depersonalization Derealization.
It's called Unreal and now it's, it's always been a grassroots charity, but it's now completely rare led and run by people with lived experience. So they, they are all extremely knowledgeable from not only their own, uh, experts by, by being experts, by experience, but also, you know, over the years they've got to know so many people with the condition.
So it's a really helpful place to go and get information that's resourced. But they run peer support groups as well, so it's worth checking in with them so that you don't feel a sense of, oh, I'm the only person that has experienced this. You've got, there's a community of [01:01:00] people. Um, and so people often describe that being very profound.
You know, something that has made them feel very isolated. Suddenly they're online and there's people all who've who know exactly what they're experiencing. So I think that's really important resource. We, myself and some other co-authors, there's, uh, an overcoming depersonalization and feelings of a reality book.
It's a self-help CBT book. Uh, it's currently second edition. We're actually just about, you know, to start working and updating that to do a third edition. So that's very helpful both for people that are experiencing it themselves, but also it's, they're usually good resources for clinicians as well, because it will talk through some of the main techniques that you can use.
It's being put in language for people that are not clinicians, but obviously clinicians can think, oh, okay, these are the sort of techniques that we [01:02:00] can use with people. Um, and then as I've mentioned, the, you know, for psychiatrists there is the online module through the Royal College of Psychiatrists that can be accessed as well.
Wonderful. I'll put some links to those in the description. Dr. In Hunter, thank you so much for joining me. I felt I learned tons today and I'm sure our listeners are gonna get a lot from it as well. Oh, thank you so much for giving me the opportunity to talk about it a bit more. And you know, as I say, always trying to raise awareness, but final messages there is hope.
So don't feel despondent if you have this, these symptoms because you can and you, you know, can get better from them. Wonderful. Thank you so much.