Loss of touch with reality

Adolescence

Sometimes people present with sleeplessness, along with mild psychotic symptoms such as odd thoughts or behavior that they recognise as irrational, or vague doubts about the intentions of neighbours or co-workers.

Shraddha, a 20-year-old Indian girl studying in the UK, called her mother late one night screaming that somebody was trying to kill her. She said her computer had been hacked into, and the hacker spoke to her through the computer. He kept telling her to run out into the traffic as she didn’t deserve to live. Sometimes he called her vulgar names and mocked her.

She had shared a flat with two other girls for a couple of years when she started her undergraduate course in the UK. Everything had been fine and the girls had become good friends. Six months ago she had begun suspecting that her flatmates were  spying on her. So she had taken to staying holed up in her room, door locked and curtains drawn. As she avoided going to the kitchen to cook, and the bathroom to bathe, her health and hygiene were neglected. She stopped attending classes and exams as well, and her grades suffered.  Finally, she moved out into a small flat to live alone. As she had informed her parents about the move and given a credible reason for it, they did not suspect anything to be amiss.

Following that phone call, her panic-stricken mother caught the first flight out and brought her home.

She came in for a consultation a day or two later accompanied by her mother. As her mother laid out the facts, Shraddha sat quietly in her chair looking utterly exhausted and blank. She did not add anything, nor did she contradict her mother. She did not even seem to register where she was, or with whom. When I asked her a simple question – was she sleeping well? – she merely directed a perplexed gaze at me but did not reply. She seemed to be somewhere else altogether.

This is not an uncommon presentation in psychiatric clinics. All the symptoms Shraddha experienced were typical:

• Hallucinations – she heard a voice saying things to her

• Delusions – she completely believed that her computer was hacked, also that her friends were spying on her

• Disorganisation – the way she had started to live, neglecting herself, lacking motivation to do things

• Social withdrawal, lack of normal feelings, poverty of speech

When people bring in a family member or a friend who has been through this harrowing experience they usually refer to it as a nervous breakdown.   In psychiatric parlance it is simply called an acute psychotic episode, meaning it is something that has suddenly happened (acute), there are symptoms like hallucinations and delusions that show a lack of touch with reality (psychotic) and it may be temporary (episode).

Sometimes people present with sleeplessness, along with mild psychotic symptoms such as odd thoughts or behavior that they recognise as irrational, or vague doubts about the intentions of neighbours or co-workers. There is an awareness of this change at a subliminal level, a feeling that something is not quite right. This is called the prodromal phase. A prodromal phase lasting a few months before the full syndrome develops is common. This might have been the clinical picture if Shraddha had presented four or five  months before. Had her mental state been examined once a week or so by a psychiatrist, treatment could have been started earlier, and the breakdown averted.

When such a person is first seen in the hospital the focus is on controlling psychotic symptoms with antipsychotic medications. However, as there are other disorders that present with psychotic symptoms in adolescence, it is necessary to wait for a few months and watch what happens. These disorders are relatively rare, e.g. tumours of the temporal lobe, metabolic diseases like disorders of copper metabolism, certain types of epilepsy, etc. Even a head injury that was not considered serious when it happened may cause similar symptoms days or months later. These can be diagnosed only by regular reviews and appropriate  investigations. It is  important to comply with the prescribed treatment, because the doctor’s next step depends on the patient’s response to medication and other parameters used to assess progress.

Early intervention is imperative. For one thing, it improves the chances of complete recovery. Secondly, there are these benefits:

• Good response to medication and lower risk of relapse

• Quicker return to school/work and normal life

• No loss of social skills, intact interpersonal relationships

• No need for hospitalization

• Reduced risk of suicide (that can happen in response to hallucinations, as it could have in the case above)

• Less stress on family members

In this series Dr Shyamala Vatsa highlights the fact that teenage changes can mask incipient mental health problems. These articles show how early symptoms of mental disorder can be taken for ordinary teenage behavior. As illustrated by the stories of young people who have suffered unnecessarily, it is important for friends and family to recognize when a behavior is outside normal limits, and seek help before things spin out of control.

Dr Shyamala Vatsa is a Bangalore-based psychiatrist who has been practicing for over twenty years. If you have any comments or queries you would like to share, please write to her at [email protected]

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psychosis

adolescence

Wonder Years

column

Shyamala Vatsa

When being ‘out of touch with reality’ is your reality

Erica Crompton

26 March 2020

In psychiatry I suffer from what is known as ‘false beliefs’ or ‘delusions’ – I hold a fixed belief that I am or will soon be Britain’s most wanted criminal.

Unshakeable beliefs

Psychosis literally means ‘out of touch with reality’ and for two decades I have lived with it. For me, psychosis means losing touch with reality and this has been near fatal at times as my paranoia can leave me feeling suicidal.

During acute psychotic episodes I have locked myself away at home as I’ve felt that this is where wanted criminals belong. Even from a place as safe as under the duvet, psychosis still affects me. During an episode, often brought on by stress, if I hear a helicopter outside I think it is the police closing in on me. I also believe the police have fitted spy equipment into my bedroom to watch me suffer. At the time of the episode these beliefs are unshakeable.

Developing psychosis

Psychosis isn’t a diagnosis in itself but it can be the tip of the iceberg for many conditions including schizophrenia, bipolar disorder, and psychotic depression – all diagnoses I’ve had at some point. For me, it took the best part of a decade for schizophrenia to be diagnosed, and with support my diagnosis has changed to schizoaffective disorder.

Often people will develop psychosis in their teens from either a family history or sometimes through taking illicit substances. But even at this stage of acute psychosis not all of this group will develop schizophrenia. This can take years before a psychiatrist may conclude that a person has schizophrenia.

There are also many other different factors to all the ‘schizophrenias’. Depression, anxiety, and mood swings are all put together to determine my diagnosis today of schizoaffective disorder.

Professor Stephen Lawrie, Head of Psychiatry at The Univeristy of Edinburgh, says:

“When mental health workers use the word psychosis, it is usually because the person they are seeing has one or more  psychotic symptoms. These are usually delusions (‘bizarre beliefs’) and/or auditory hallucinations (‘hearing voices’).

“A diagnosis of a psychotic disorder (or condition) is usually only made if the symptoms are distressing or interfering with everyday life, but it often also means that the person does not realise that they are ill – in other words, in psychiatric jargon, they ‘lack insight’ that their experiences are products of their mind rather than real”.

The difficulty of disclosure

A psychiatric assessment is given before diagnosis and this will be clinical. Psychiatrists will assess the mental state in which the patient is presenting. Sometimes patients are scared to express the full extent of their experiences, making a schizophrenia diagnosis less likely.

For example, a lady with bipolar disorder with psychotic features might not tell her psychiatrist about all her symptoms for fear of the outcome or even being locked away. She may confide in a professional other than a psychiatrist such as a Support Worker or Occupational Therapist who can then refer her back to her psychiatrist who will likely commence anti-psychotic medication.

Dr Vijayakumar Motappashastry, Locum Consultant Psychiatrist, Midlands Partnership NHS Foundation Trust, UK, tells me: “I have treated patients with schizophrenia for 25 years as a psychiatrist. It’s a very complex condition and not at all straightforward to diagnose.

• See more: The label of bipolar disorder has freed me rather than pigeonholed me
• See more: What it’s like to hear voices and how ‘democratic psychiatry’ can help

“We cannot diagnose schizophrenia immediately – rather, it takes several assessments, plenty of time, we need to take into account the patient’s family history, and collateral using a structured assessment. Only after all of these steps can schizophrenia be diagnosed. I must stress the time it will take clinicians like me to make a diagnosis”.

Being psychotic, or ‘out of touch with reality’ can thankfully be managed. I have lived with this condition for almost two decades and manage it with a combination of anti-psychotic medication, talking therapies, and lifestyle choices such as regular exercise and eating well. While it has been a hard illness to cope with, not least because of stigma from others, it is not a life sentence.

Erica Crompton is the co-author of The Beginner’s Guide to Sanity: A Self-Help Book for People with Psychosis – written with Professor Stephen Lawrie (published by Hammersmith Health Books)

Depersonalization: a syndrome that interferes with feeling – BBC News Ukraine

• Adam Iley
• because of her illness, familiar places seem like decorations

  People with depersonalization syndrome, the world seems unreal, two-dimensional, as if in a fog. Every hundredth suffers from this disorder, but despite this, British doctors are not taught to work with such patients, experts say.

  “The connections you think are valuable lose their original meaning. You know you love your family. But the thing is, you’re more aware of it than you feel it,” says Sarah on the BBC’s Victoria Derbyshire program .

  Sarah is an actress, she constantly tries on different images and reproduces other people’s emotions. But in reality, for most of her conscious life, she is emotionally paralyzed and unable to experience any feelings.

  The reason for this is a little-studied mental disorder called depersonalization.

  Sarah had the syndrome three times. The first time it happened was when she was preparing for her final exams.

  The main sign of depersonalization is the feeling that a person loses physical connection with the world around him and his own body.

  It is believed that this is how a defense mechanism manifests itself when, during stress or a serious shock, consciousness is disconnected from reality. Some drugs, such as marijuana, can cause the same effect.

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  For people with depersonalization syndrome, the world can change in a second.

  “It was an unexpected switch. Everything around seemed alien and even intimidating. Suddenly, the apartment and other places where you used to be become a film set for you, and all your things become scenery,” says Sarah.

  Other patients report feeling that they are outside their body, that it does not belong to them, and that the world around them seems two-dimensional and flat.

  This happened to Sarah during the second episode.

  “I was reading, I had a book in my hands. And suddenly my hands began to look like a picture on which two hands were drawn. There was a feeling that the real world and my perception of it did not coincide.”

  Sarah’s disorder is not uncommon. Three independent studies have proven that it occurs in one person out of a hundred.

  Experts argue that the disorder has long been recognized as a medical disease. It is as common as obsessive-compulsive disorder or schizophrenia.

  Some untreated patients may suffer lifelong symptoms of depersonalization. And yet, not all doctors know what it is.

  A doctor who recently graduated and suffers from this disorder himself stated that depersonalization was not taught in medical school or in continuing education courses for therapists.

  He admitted that he had misdiagnosed his patients at least twice. According to him, he will be very surprised if it turns out that at least one of his colleagues has heard about this syndrome.

  Sarah says that she has encountered at least 20 professionals in her life who had no idea what she was talking about. Among them are consultants, therapists, district psychiatrists and doctors.

  The Royal College of General Practitioners (RCGP) in London said that mental health was a key element of an expanded curriculum for physicians.

  The institute added that the study of more complex psychological problems is still in development.

  The Royal College of Psychiatry stressed the need to ensure that these disorders are properly understood.

  Photo caption,

  Dr. Elaine Hunter runs the only referral center in the UK that treats patients with depersonalization

  Poor diagnosis is only part of the problem, access to treatment is another complication.

  There is only one specialized clinic in the UK. Its resources are limited, it can only accept 80 patients a year. Despite the fact that 650 thousand people can potentially suffer from this disease.

  A referral from a local doctor is required to access this health center free of charge. And even if the patient is diagnosed with depersonalization, treatment will have to wait several months or longer.

  After a year of waiting in line, Sarah decided that the only way out was to pay for the treatment herself.

  “I used to have panic attacks all the time. It’s really scary. I knew it was a crisis,” she says.

  A specialist center for patients with depersonalization syndrome operates at the Maudsley Hospital in south London. However, there are restrictions for patients under 18 years of age; the center only treats adults.

  Often the disease occurs in adolescence. Dr. Elaine Hunter, who heads the center, is concerned that she has to withhold care for children and adolescents.

  “Sometimes fifteen-year-olds who are deeply depressed and frightened come to us, but we have nothing to offer them,” she says.

  One of the adult patients of the center developed the syndrome at the age of 13. For two years she could not leave the house, she experienced ten panic attacks a day caused by the disorder.

  At the beginning of the treatment, she did not even recognize her own parents.

  Dr. Hunter hopes that over time, the right treatment will be available to underage patients.

  She believes that treatment should be organized in every district. Physicians in local centers for psychological assistance should undergo special training, then disseminate information among other specialists.

  Photo caption,

  Sarah Ashley couldn’t eat or sleep until after her therapy with Dr. Hunter

  Hunter has developed Cognitive Behavioral Therapy (CBT) specifically for patients with depersonalization. She believes that she will be easily mastered by doctors who already have experience in talking therapy.

  Sarah Ashley, a patient of Dr. Hunter, says she was initially skeptical about the technique, but after a while she felt a huge difference.

  “[Before CBT] I looked at my own hands or other body parts and felt like they weren’t mine. I looked at myself in the mirror and didn’t realize it was me,” explains Sarah.

  “I couldn’t eat or sleep, and due to stress I lost 42 kg. Now I still have some symptoms, but I can get over them quickly,” she continues.

  Treatment is available but difficult to obtain.

  As Dr. Hunter says, we need to correct the situation in which patients are forced to look up information about their disorder on the Internet, and then explain to the doctor what it is about. Instead of, on the contrary, the doctor told the patient about his illness.

  What is depersonalization and how to live with it

  Impairment of the perception of one’s own “I”, a feeling of unreality of what is happening, anxiety attacks, panic attacks and loss of emotions – these are the symptoms of depersonalization disorder, which is often confused with schizophrenia. Afisha Daily publishes three stories of people with this terrible diagnosis.

  Tatyana, 28 years old: “For the first time I encountered a feeling of unreality of what was happening when I was 22 years old. One day, I just stopped feeling any emotions; my relatives suddenly became strangers, I didn’t want to communicate with anyone, go out anywhere. I didn’t feel like myself – the personality was erased, and I became a different person: the feeling that there was no more soul, only one shell. This was accompanied by constant anxiety, soul-searching, headaches, and a sense of hopelessness. This is a terrible state when suicide seems to be the only way to stop everything.

  I was very frightened and urgently called my mother, because I myself could not even go to the doctor. The neurologist at the hospital said that I was depressed and prescribed a cocktail of antidepressants and neuroleptics. Surprisingly, almost from the first days of taking the pills, I returned to life: the symptoms disappeared, my mood improved, my ability to work increased, I became sociable and open. A month later, I stopped taking these drugs and did not go to the doctor again (although I was warned not to give up the drugs). For four years, I forgot about the problems.

  The symptoms returned when a relative offered me a new job. There were rather high requirements for employees – a mandatory driver’s license, specialized education in the field of shipping and fluent English. I was given six months to prepare. The relative paid for all the courses, the university – and then the stress began. I felt that it was covering me, so I arbitrarily returned to the pills. It got a little easier for a while. I tried my last strength not to lose face, to get this job, not to let down the person who believed in me and also spent money. But I got worse and worse, and I failed the job interview. It was a very difficult period.

  After that, I began to sit on forums, google articles about mental disorders with similar symptoms. There were thoughts that I had schizophrenia and I was finally going crazy. I started running around psychiatrists, but all of them refuted my suspicions. Depression was re-diagnosed, antidepressants were prescribed – anxiety subsided a little, but emotions and feelings never returned.

  Once on some website I saw a description of a diagnosis that exactly matched my symptoms. Then my acquaintance with depersonalization-derealization disorder began. I went to doctors, but they basically didn’t know what it was and how to treat it. Sometimes they simply did not want to listen to me – they immediately prescribed medicines and sent me home. One professor said that I “read on the Internet.” I found my salvation in online consultations with a doctor who dealt with dereal: according to his scheme, I started taking antidepressants and antiepileptic drugs.

  The reason for my depersonalization is neurosis, which is accompanied by anxiety: under stress, the body defends itself and the brain seems to turn off, isolation from the outside world occurs. This happens to impressionable people who worry about anything, take everything to heart. I am one of those.

  My experience is 2.5 years. I know that there may be deterioration, but there is a way out. Now I have reached the stage when a new job is a joy, I feel like myself again, mental abilities, emotions and feelings are the same as before the illness. And, although I’m still on the pills, it’s better than suffering again. I hope someday I can cancel them. It sounds strange, but this illness has changed me for the better. Thanks to her, I truly began to appreciate life and loved ones. Became more patient. I am glad that I can live a normal life again, feel, love, enjoy communication with people and from my favorite activities.

  Our society is very contemptuous of those in need of psychological help. If they find out that a person has been to a psychiatrist, they immediately label him a psycho and avoid him. Nevertheless, you should not be afraid to seek qualified help, the main thing in this matter is to find a really good doctor. And there are very few of them.”

  Nikolai, 27 years old: “I have been neurotic since childhood: stuttering, obsessive-compulsive disorder (obsessive thoughts syndrome). In August 2014, I went to a psychiatrist with depression and impaired perception of reality, I was then 25 years old. It all started with rare panic attacks, which were replaced by bouts of severe derealization. The world turned upside down, and I had to lie down on the floor and close my eyes, this helped to come to my senses. After another such attack, I developed anxiety.

  For exactly 6 months I have been thrashing around looking for and inventing physical illnesses to justify my condition. Admitting to yourself that you are a little “cuckoo” is difficult, and this is how hypochondria appears. The catalyst for hypochondria is still such an unpleasant reality as unskilled medicine. The inertia coming from the USSR still persists – doctors sculpt a diagnosis of VVD (which has long been absent from the world classification of diseases), say that everything is in order, prescribe vitamins and send them home. Therefore, I had to engage in self-diagnosis and be terribly afraid of what was really happening to me. Unfortunately, I made the diagnosis of “depersonalization disorder” myself, once again surfing the Internet. Through acquaintances, I managed to go to a psycho-neurological dispensary. There I was pumped with the same Soviet drugs, put on droppers, there was even a massage and a circular shower. At discharge, there were no significant results: it became easier to sleep, but the condition remained the same painful.

  Finally, miraculously, I managed to get to a good psychiatrist. Properly selected drugs have built a solid foundation for my recovery. Now pharmacology has reached such a level that drugs work reliably with a minimum of side effects and consequences for the body. Of course, they do not eliminate psychological problems, but they provide a runway for climbing to the height where these problems could be eliminated. The antidepressant began to noticeably act somewhere in 3-4 weeks after the start of the reception. The mood improved, strength appeared, life began to bring pleasure. Then slowly: communication with friends began to recover, I began to go out, my libido and the desire to do something woke up. I recovered at work: when getting to the toilet is a huge test, work becomes something unbearable.

  Depersonalization is, in the usual sense, the loss of oneself; when you can’t understand what kind of person you are. Recovery after this leads to a rethinking of life attitudes. For example, in the past I limited myself, tried to conform to the ideas dictated by society. He lived according to the principle “as it should be”, and not “as I want”. During this period, the understanding of one’s person is lost: who are you? why are you? who are you supposed to be? You are depersonalizing. At the turning point of frustration, you understand that you need to live for yourself, and not for others, you stop constantly looking for flaws and correcting them in order to become someone. I accepted myself.”

  Anastasia, 20 years old: “At school, I was often bullied because of my excess weight, no one took me seriously at home, there were constant screams and scandals because of my father’s alcohol addiction. At the age of 15, I decided to try drugs and, not knowing the “correct dosages”, I took too much at one time. After that, my health deteriorated sharply: short-term panic attacks began, heart palpitations, unsteadiness of gait, dizziness appeared. At first I thought that I had something with my heart or blood vessels; over time, this developed into a fear of a heart attack, stroke, or sudden death. Then there was an examination of the whole body, but nothing concrete was found out: the doctors either did not find anything, or made a diagnosis of “vegetovascular dystonia”. One doctor advised me to get tested for cancer.

  Over time, the situation progressed. There was a terrible feeling inside, like anxiety: I couldn’t sleep normally, it seemed that I would die any minute. One day I realized that I did not feel my body. There was a feeling of lightness and weightlessness at the same time, and then I began to catch myself thinking that it was as if I were not there. The sensations in my hands became not mine, the reflection in the mirror was not the same. Then I realized that I was in danger not of a heart attack, but of schizophrenia. I completely surrendered to this fear: the physical symptoms disappeared, there was an indescribable horror that now I would lose touch with reality and control over myself. I began to hide the handle from the balcony so that in a fit of unconsciousness the window would not suddenly jump out. The world as I knew it was shattered. Going out into the street, I understood that there was a big barrier between me and reality. The world behind the glass seemed flat, colorless, dead. I couldn’t figure out if this was a dream or reality, or maybe I had died altogether. Time just stopped, it didn’t exist, it didn’t exist for me. And in the soul there is emptiness, silence and no emotions.

  I found out that this is not schizophrenia on a site about dissociative disorder. Thus began a new phase. On VKontakte, I found a group about dereal, where there were hundreds of people like me. For about a week I sat in the community, reading information, personal stories and recommendations, until I fully understood that this was it – depersonalization-derealization disorder.

  In the 11th grade, everything got to the point that I was taken from the USE in an ambulance. When I went to the doctor, he started asking something, and I was silent: I was so tired of this shit that I could not say a word. My parents found out that I have serious mental problems. It seemed to me that my mother did not understand me. I was again taken to the doctors, but we failed to find an intelligent specialist. In Soviet-era hospitals, doctors are not at all familiar with depersonalization: in one of these, I was prescribed 12 dubious pills a day, and glycine was also completely useless for my symptoms. There were doctors who were more interested in my outlook on life than my health.

  As a result, I found my psychiatrist, with whom we still keep in touch, through my mother’s friend. If we talk about treatment, then you can’t do without antidepressants. They help to return to the previous mode and significantly improve the condition. Now I’m 20, and I’m still on pills: I decided that it’s better to feel good with them than to think about suicide every day.

  “The depersonalization-derealization syndrome is based on the attempt of the psyche to adapt to stress in conditions of its high intensity, for example, during fear or panic. This syndrome as a separate disorder is included in the international classification of diseases (ICD-10), but often occurs as a secondary syndrome with severe anxiety, depression and other acute conditions. Depersonalization and derealization, although combined into one term due to their similarity and general nature, represent two independent symptoms that can manifest themselves separately from each other. During depersonalization, the patient’s own face, figure, smile, speech seem unfamiliar, as if you are watching yourself as an outsider. Derealization, on the other hand, concerns the perception of the environment: place, time, circumstances, etc. Sometimes a feeling of “drunkenness”, “unreality” and “floating picture” is added.

  The main cause of DP/DR lies in the activation of opiate receptors – there is an assumption that in this way the human body tries to reduce severe anxiety. Stress can become a reason if it was intense and caused a vegetative crisis (like a panic attack).

  Feelings during depersonalization-derealization frighten with their unusualness. It seems to the patient that he has lost control of his own body, and this in itself provokes even more intense fear. It differs from schizophrenia primarily in the absence of symptoms of psychosis (hallucinations, delusions, catatonia, etc.). Also, the DP / DR syndrome can be observed in acute psychotic episodes, but then there must be appropriate mandatory symptoms of a severe mental illness.

  Despite its prevalence, this diagnosis is not fully understood in terms of mechanisms and origin, which leads to difficulties in therapy. In the US, the disorder is treated primarily with antidepressants and lamotrigine. In Russia, there are no clear standards and recommendations: in DP/DR, they often look for the “main disorder”, hoping that the syndrome will recede on its own. It is not uncommon for depersonalization or derealization to resolve quickly if it occurs in the context of a panic or other anxiety disorder, but it can take years to treat these disorders in depression and bipolar affective disorder.