Cases That Test Your Skills The woman who wasn’t there Ahmed Janjua, MD, Daniel Rapport, MD, and Gina Ferrara, MD How would you Since a night of heavy drinking 4 years ago, Ms. A has felt handle this case? detached from reality and confused. Various antidepressants Visit CurrentPsychiatry.com to input your answers and anxiolytics have not helped. What would you try next? and see how your colleagues responded CASE Feeling detached borhood, having her car broken into, her father’s Ms. A, age 23, presents to our clinic complain- disapproval of her fiancé, and wanting to get ing of feeling detached for the past 4 years. married. She drank heavily in college, but has She says she feels “fuzzy all the time, like I lost used alcohol infrequently since then. touch with reality 4 years ago and really miss Ms. A’s father has a history of anxiety. She it.” She complains of “confused thinking,” ex- describes him as domineering and her mother cessive tiredness and weakness, depression, as very emotional and always wanting to be and anxiety. She says, “It feels like I’m watch- her friend. Ms. A says she struggles with re- ing my life on television; I don’t feel any emo- lationships, employment, and plans for ad- tions.” These symptoms began immediately vancement, all of which are moderately to after a college party, which the police stopped severely affected by her depersonalization because of underage drinking. She says, “I symptoms. During the initial appointment, don’t know why, but that party set it off, and it we diagnose Ms. A with generalized anxiety feels like I am in a dream all the time.” disorder, panic disorder, and major depressive For the last 4 years, Ms. A has been work- disorder (MDD). ing as a waitress and is now engaged. She presents to our clinic because the treatments Which diagnoses would you include among she has been receiving are ineffective and she the differential diagnosis? wants to feel her emotions again, especially a) posttraumatic stress disorder (PTSD) before her wedding. b) MDD with psychotic features Ms. A has no history of mania, depression, c) depersonalization disorder or psychosis. She says she was an anxious d) schizophrenia, undifferentiated type child and suffered from anorexia nervosa be- e) psychosis not otherwise specified tween age 13 and 14. She experienced occa- sional panic attacks beginning in high school The authors’ observations that were triggered by feeling overwhelmed Depersonalization symptoms can occur in or frustrated with not feeling normal. During a variety of situations, including: these panic attacks, Ms. A experienced tight- Dr. Janjua is a third-year psychiatry resident, University of ness in her chest and dizziness. She denies sui- Toledo Medical Center, Toledo, OH. Dr. Rapport is associate cidal or homicidal ideation or attempts. professor of psychiatry and director of the consultation-liaison At age 18, she was sexually assaulted. Ongo- service, University of Toledo Medical Center, Toledo, OH. Current Psychiatry Dr. Ferrara is second-year child/adolescent psychiatry fellow at 62 April 2010 ing stressors include living in a dangerous neigh- the University of Southern California, Los Angeles, CA. Cases That Test Your Skills Table 1 Assessing for depersonalization: 3 rating scales Scale Description Cambridge 29-item, self-report questionnaire meant to capture frequency and Depersonalization Scale5 duration of depersonalization symptoms over the previous 6 months Depersonalization Covers a range of axis I and II psychopathology Severity Scale6 Dissociative Experiences 28-item, self-report instrument to measure dissociation Scale7 • mentally healthy persons suffering from assault, she does not meet criteria for PTSD acute stressors, fatigue, or drug use because she denies re-experiencing the as- • neuropsychiatric conditions such as sault, hyperarousal, and avoidance behaviors. Clinical Point epilepsy Ms. A meets all 4 DSM-IV-TR criteria for Rating scales and • migraine depersonalization disorder (Table 2, page 64). • anxiety disorders She experiences persistent feelings of de- DSM-IV-TR criteria • depressive disorders tachment, which cause her considerable dis- can help differentiate • schizophrenia.1 tress. Her reality testing is intact and these transient symptoms Transient depersonalization symptoms experiences are not due to a general medical from a disorder and are common and have been found in 2.4% condition, another mental disorder, or direct assess severity of the general population.2 Community physiological effects of a substance. surveys using standardized diagnostic in- terviews reveal 1-month prevalence rates of Which medications would you consider for 1.6% to 1.9% in 2 UK samples.3,4 Deperson- Ms. A? alization symptoms are brief and less de- a) benzodiazepine plus a tricyclic anti- bilitating than depersonalization disorder. depressant (TCA) Depersonalization rarely presents as a b) selective serotonin reuptake inhibitor primary disorder, when symptoms persist (SSRI) plus a benzodiazepine chronically. Rating scales (Table 1)5-7 and c) trazodone plus bupropion DSM-IV-TR criteria (Table 2, page 64) can d) atypical antipsychotic plus a benzodiaz- help assess symptom severity and differen- epine and a TCA tiate transient symptoms from a disorder. Psychiatric conditions that commonly are comorbid with depersonalization disorder TREATMENT Insufficient response appear in Table 3 (page 71).8 Triggers for a Ms. A’s previous psychiatrist prescribed various first episode of depersonalization disorder SSRIs and selective serotonin-norepinephrine include: reuptake inhibitors, including sertraline, esci- • psychological stressors (31%) talopram, citalopram, paroxetine, and venla- • substance abuse (25%) faxine, for depression and anxiety with little or • physical stressor (12%) no benefit. When she presented at our clinic, • situational stressor (17%) Ms. A was taking clonazepam, 0.25 mg as • social and/or relationship problems needed, and fluvoxamine, 50 mg/d, which she (10%) said helped her anxiety a little, but not deper- • trauma (6%) sonalization symptoms. She received support- • panic/anxiety (2%).8 ive psychotherapy provided during biweekly Although Ms. A experiences deperson- 30-minute medication management visits. alization—constant numbness and empti- We add aripiprazole, 2.5 mg/d, to augment Current Psychiatry ness—when she thinks about the sexual fluvoxamine’s antidepressant effect and reduce Vol. 9, No. 4 63 Cases That Test Your Skills Table 2 DSM-IV-TR criteria for depersonalization disorder A. Persistent and recurrent experiences of feeling detached from oneself and as if one is an outside observer of one’s mental processes or body. B. During the depersonalization experience, reality testing remains intact. C. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as schizophrenia, panic disorder, acute stress disorder, or another dissociative disorder, and is not due to the direct physiological effects of a substance (eg, a drug of abuse or a medication) or a general medical condition (eg, temporal lobe epilepsy). Source: Diagnostic and statistical manual of mental disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association; 2004 Clinical Point her anxiety and dissociative symptoms. At the anxiety and depression. After 2 weeks, Ms. A Depersonalization next visit 5 weeks later, she reports her dep- says her anxiety and depression have resolved disorder is associated ersonalization symptoms gradually lessened completely but the depersonalization symp- with HPA axis from 10 to 6 on a 10-point self-report scale. toms persist. We restart amantadine, 100 mg dysregulation We discontinue fluvoxamine after 5 weeks as needed, for anorgasmia. and lower basal because it no longer significantly contributes Because of her persistent complaints of de- to her recovery. We add amantadine, 100 mg/d, personalization, after discussion with Ms. A, cortisol levels based on the belief that dopamine augmenta- we decide to return to what had helped her tion might help reduce her symptoms. Ms. A at the beginning of treatment and restart ar- reports improved depersonalization symptoms ipiprazole, 2.5 mg/d. Four months later, she over the next 4 weeks (5/10). However, a week reports her depersonalization symptoms have later she says she feels her anxiety is worsen- resolved completely. At this time, her regimen ing the depersonalization symptoms. We start consists of clomipramine, 50 mg at bedtime, buspirone, 7.5 mg/d titrated to 15 mg/d over diazepam, 10 mg at bedtime, and aripiprazole, 4 weeks, Ms. A reports feeling worse so we dis- 2.5 mg/d. continue the drug. Next Ms. A complains of excessive sleepiness, Which neurotransmitter systems have been which seems to be related to amantadine, so we implicated in depersonalization disorder? discontinue it. We start bupropion, 150 mg/d a) HPA axis and titrate it to 450 mg/d, which we hope will b) serotonin system reduce her fatigue, anxiety, depersonalization, c) norepinephrine-dopamine system and depression. Bupropion’s effect on norepi- d) dopamine-serotonin system nephrine and dopamine reuptake and a study of e) all of the above autonomic blunting in depersonalization9 justify our selection. The authors’ observations After 3 months, Ms. A stops taking aripip- The neurobiology of emotion processing razole because it