Medication

DPAFU involves a change in the state of mind. Because our brain activity provides the basis for our states of mind, experiencing DPAFU is associated with changes in the brain. This isn’t to say that there is anything physically wrong with the brain. Indeed all the evidence suggests that the brain appears physically normal in people with DPAFU. However it seems likely that parts of the brain behave differently when people are experiencing the sensations of DPAFU compared to when they are not. This is probably because of the way different parts of the brain communicate with each other. Communication between parts of the brain involves chemicals called neurotransmitters. There are many different kinds of neurotransmitter, and medication works by changing the amount, or the activity, of one or more of them. In this way, medication can help treat a range of psychological problems, such as depression or anxiety.

Are there any medications that might be helpful for people with DPAFU?

The first thing to say is that there is currently no well-established drug treatment for DPAFU. At the time of writing, no medication has been specifically licensed (i.e. approved by the regulating authorities) to tackle DPAFU. It is therefore essential that any drug treatment is undertaken with specialist supervision. Having said this, there has been some research on possible treatments. A number of medications have been reported as being helpful in individual cases, but it is difficult to know whether these success stories can tell us much about DPAFU in general. For example, in one individual there is no way of knowing whether the person would have improved anyway, with or without the medication. To really know whether a medication is helpful, we need to look at larger studies. A few drugs have been studied for possible beneficial effects in treating DPAFU, including fluoxetine (Prozac) and clomipramine (Anafranil), but the results have not been particularly encouraging.

Clomipramine is an example of a tricycic antidepressant, as are amitriptyline, nortriptyline, doxepin and imipramine. Fluoxetine is an example of a serotonin re-uptake inhibitor (SSRI), as are citalopram, sertraline and paroxetine. There are other drugs called mono-amine oxidase inhibitors (MAOIs), such as phenelzine, and serotonin and noradrenaline re-uptake inhibitors (SNRIs), for example venlafaxine.

The main use of all of these classes of drug is to treat depression. Most have been around for many years and all have passed international standards of safety and efficacy. They all need to be prescribed by a qualified doctor. They all have side effects and certain benefits and drawbacks. For further information, see Appendix II.

Your doctor may have prescribed one or more of these drugs to you for depression, or a mixture of depression and anxiety or even to help with sleep problems or physical symptoms like chronic pain. If your doctor feels that one of these conditions underlies your DPAFU then that obviously makes sense. What we can say however is that, if you’re only suffering from depersonalization, and if the depersonalization is relatively severe, these drugs don’t always work.

One medication that has shown promising results in treating DPAFU is lamotrigine (Lamictal). Lamotrigine works primarily by influencing a neurotransmitter called glutamate.

Lamotrigine was originally designed to treat certain kinds of epilepsy, but its use in DPAFU doesn’t mean that DPAFU is a form of epilepsy. The idea of using lamotrigine to treat DPAFU came from the discovery that it can prevent the depersonalization usually caused by ketamine (an anaesthetic drug that’s sometimes used illicitly at clubs or raves). This led us to wonder whether lamotrigine might be helpful to people with DPAFU. Early observations were sufficiently encouraging for us to make lamotrigine a regular choice of drug treatment for DPAFU. We now have considerable experience in the use of lamotrigine for DPAFU and have conducted three studies of its effectiveness. Overall we’ve found that lamotrigine has a beneficial effect in around 50 per cent of people with DPAFU, but this figure rises to around 70 per cent when lamotrigine is combined with an antidepressant medication such as citalopram. These figures suggest that, although lamotrigine isn’t a wonder drug, it can have a useful role in treating DPAFU, either by itself or in combination with another medication. However it should only be prescribed by a specialist, that is a psychiatrist who is able to supervise the treatment, make changes and monitor progress as appropriate. We repeat, lamotrigine is not licensed for the treatment of DPAFU.

When people first start taking lamotrigine, they should begin with a small dose of 25 mg per day. This is increased by 25 mg every two weeks, so that after two weeks they will start taking 50 mg per day, then two weeks after that the dose will rise to 75 mg per day, and so on. Once the dose is over 100 mg per day, further increases can safely be made in steps of 50 mg every two weeks. The maximum dose used in our clinic is around 400 mg per day. The reason for building the dose up gradually like this is that it reduces the risk of side effects. This is important because lamotrigine can cause a disorder of the blood cells – this happens to about 1 in 2,000 people who take it. To guard against this, the dose is built up slowly and people taking lamotrigine are advised to have blood tests in the early stages of treatment. The tests monitor their blood cell counts and their liver and kidney function. Another possible side effect of lamotrigine is a skin rash. Occasionally this may be serious, and for this reason anyone taking lamotrigine is advised to stop taking it immediately if a rash develops. Having said that, it should be stressed that the vast majority of people who take lamotrigine do so without experiencing unpleasant side effects.

In the early stages of treatment, most people feel little or no benefit from the lamotrigine. Usually it’s not until the dose reaches 100 mg per day that people notice some reduction in their symptoms of DPAFU. The ‘right dose’ varies between individuals. Most people who benefit significantly from lamotrigine do so at a dose of between 200 and 400 mg per day, but others need a much higher dose. Some people report that the symptoms of DPAFU have completely lifted, while others say that the symptoms are still present, but are less intense and have less of an impact on their lives. When people have a good response to lamotrigine, we advise them to stay on the medication for a year before gradually reducing the dose down to zero. The withdrawal can be done over a period of two or three weeks.

As we’ve said, some people do not respond to lamotrigine, but at present we have no reliable way of predicting who will respond to it and who won’t. However, if lamotrigine doesn’t help, there are various other possible drugs. Clonazepam (Rivotril, Klonopin) is another epilepsy medication, although it works in a different way to lamotrigine. As well as its role in treating epilepsy, it’s useful for controlling anxiety and agitation. We saw earlier in this book (see page 119) that there’s often a relationship between anxiety and DPAFU. Clonazepam can be very effective in reducing anxiety, and some people with DPAFU find that it also decreases their DPAFU symptoms.

As with lamotrigine, there is a range of possible doses. Most people take between 1 mg and 8 mgs per day, either as a single dose or split between morning and evening doses. Clonazepam can be very helpful, but it’s important to know that in some people it can become habit-forming and that coming off it may involve a period of gradual withdrawal by dose reduction. Use of clonazepam should be carefully discussed with your GP or psychiatrist before starting treatment. Once again, we must emphasize that clonazepam is not licensed for the treatment of DPAFU.

Another medication that may help with DPAFU is naltrexone (Nalorex). Two small studies have shown some evidence of a beneficial effect in DPAFU. However, at the time of writing information on its effectiveness in treating DPAFU is very limited. We are currently studying it as a possible treatment for DPAFU and hope to have more information available in the near future.

‘Major tranquilliser’ or ‘antipsychotic’ medications such as chlorpromazine, olanzapine, or risperidone are usually used to treat serious mental illnesses such as schizophrenia, and are not recommended for DPAFU. There is currently no theoretical reason for believing they will be helpful, and people with DPAFU who have been prescribed these drugs in the past have usually told us that they brought about a worsening of the symptoms. If you’ve been prescribed one of these drugs, it may be that your problems go beyond simple depersonalization or derealization. If you have any concerns, you should discuss them with your doctor. You should certainly not stop any part of your treatment before seeking such advice.

To sum up, various medications can be helpful for DPAFU. To date, the best results we’ve obtained in our specialist clinic have been with lamotrigine, particularly when it’s given in combination with an antidepressant. If lamotrigine doesn’t prove helpful, there are alternatives that can be tried. There is no reason why medication cannot be combined with psychological treatment, in fact it is probably best if it is combined in this way, although some people prefer to undertake one mode of treatment – psychological or pharmacological (drug-based) – without the other.

You should discuss your sensations of DPAFU with your doctor before taking any medication. Remember to tell him or her if you are taking any other medications, as some medications can interact with those discussed here. Also be sure to mention if you are pregnant or breastfeeding, because some medications should be avoided at these times.