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ECEM: Eye Closure and Eye Movement in the Treatment of Panic Disorder and Depersonalization Disorder. Director, Milton H. Erickson Institute, NJ 20 Nassau Street Princeton, NJ 08540 Objectives. Define depersonalization disorder (DPD). Differentiate:

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ecem eye closure and eye movement in the treatment of panic disorder and depersonalization disorder

ECEM: Eye Closure and Eye Movement in the Treatment of Panic Disorder and Depersonalization Disorder

Director, Milton H. Erickson Institute, NJ

20 Nassau Street

Princeton, NJ 08540

  • Define depersonalization disorder (DPD).
  • Differentiate:
    • Symptoms of depersonalization in DID, PTSD, and DPD as a subtype of panic disorder
    • Differentiate panic disorder and DPD
  • Learn about ECEM: utilization of eye movements (adapted from EMDR) within hypnosis
  • Apply ECEM to panic and DPD
defining dpd
Defining DPD
  • DPD is characterized by dissociation, depersonalization and derealization, in the absence of disrupted memory or identity. (Knutelska 2004)

DPD involves:

  • Persistent or recurrent experiences of feeling detached from the self, as if one is an outside observer of one’s mental processes or body, e.g., feeling like one is in a dream, "feeling unreal."
dpd symptoms
DPD symptoms
  • Sensory and affective blunting, cognitive freezing, impaired attention, perceptual changes.
  • De-realization ( De-realization is a distinct disorder but rarely occurs on its own).
  • Despite "feeling unreal," reality testing remains intact.
  • There is anxiety and distress.
  • No gender differences
  • Age of onset is between 16 and 21
  • DPD is a chronic disorder with intermittent episodes.
precipitating factors
Precipitating Factors
  • Precipitating factors include interpersonal stress, reactions to medication, negative affects, perceived threatening situations, unfamiliar environments
  • The onset of DPD may be traced to drug use, but is not maintained by the use of alcohol or drugs
dpd is conceptualized as a subtype of panic
DPD is conceptualized as a subtype of panic

There is an overlap of symptoms:

Attacks seem to come out of the blue

  • There are avoidance behaviors which maintain the disorder
  • There is a high level of anticipatory anxiety
  • There is excessive self-monitoring in anticipation of attacks, fear of loss of control, fear of going crazy, belief something terrible is happening, that cannot be controlled.
differences between panic and dpd
Differences between panic and DPD
  • Breathing distress is central to panic.
  • Maladaptive breathing patterns (breath holding) often goes unrecognized by persons with DPD until pointed out.
  • Most (73%) of persons with DPD have a history of panic disorder Segui, et al., 2000
treatment approaches
Treatment approaches
  • DPD has been found refractory to most medications (SSRI"s, anxiolytics)
  • DPD is refractory to well known therapies.
    • Cognitive behavior therapy emphasizes learning to "live with it,", " get through it" but CBT does not address the core symptoms of feeling unreal, sensory blunting, etc.
  • EMDR is ineffective with panic disorder,
  • EMDR has not been studied for DPD, probably because EMDR can precipitate panic, dissociation and de-stablization in vulnerable persons, especially those with DID, or a history of severe trauma/and or child abuse.
exclusionary criteria for dpd
Exclusionary criteria for DPD

Symptoms of depersonalization appear in schizophrenia, epilepsy, dissociative identity disorder (DID),and PTSD but are differentiated from them.

In DID "parts" are walled off from the main personality. There are discontinuities of time that are unlike dissociation in DPD.

dpd and ptsd are distinct disorders
DPD and PTSD are distinct disorders
  • Persons with PTSD may have DP symptoms but persons with DPD may not have symptoms of PTSD--they may have adverse events but not trauma.
  • PTSD is a disorder of emotional regulation involving the medial-frontal lobe that modulates lower level appraisal functions such as the amygdala and anterior cingulate resulting in hyperarousal or hypoarousal-- two non-verbal reactions to stress.
hyperarousal and dissociation are different
Hyperarousal and dissociation are different
  • Hyperarousal--reliving, flashbacks--comes from reduced “top down” control of affect involving relative decrease in activity in the medial prefrontal cortex and relative increase in activity in the amygdala (implicated in the alarm function).
  • Hypoarousal or dissociation/depersonalization is related to super suppression in the medial prefrontal cortex anterior cingulate cortex, reduced thalamic activity and increased activity in the inferior frontal gyrus.
  • Lanius, et. al. 2005 Biol. Psychiatry. 57: 873-84
dpd as a function of supersuppression in the mpfc
DPD as a function of supersuppression in the MPFC

Supersupression of the MPFC and increased activation of the inferior frontal gyrus (associated with awareness of body states) is implicated in out of body experiences.

  • Greatly decreased activity in thalamic structures reflects a failure of the stress system, to meet the emergency needs of stress arousal, and is shown in freezing, dissociation, lowered heart rate (my heart stopped) sense of physical paralysis, loss of speech, inability to think, emotional numbing, out of body experiences
  • Lanius, et. al. 2005 Biol. Psychiatry. 57: 873-84
  • .,
neurophysiological theories of dpd
Neurophysiological theories of DPD

The noradrenergic system is central to DPD and involves the locus ceruleus

  • Locus ceruleus (blue spot) is cluster of several hundred neurons located in the limbic system at juncture of pons and midbrain with projections to all parts of CNS.
dstinctions between panic and dpd
Dstinctions between panic and DPD
  • Overactivity in the locus cereuleus and high release levels of norepinephrine is associated with panic attacks.
  • Under-reactivity in the locus ceruleus results in a deficit of norephinephrine, a failure to meet the needs of stress, and is associated with depersonalization symptoms.
neural basis of dpd
Neural basis of DPD
  • In PTSD, dysregulation of the locus ceruleus overproduces norepinephrine which at high levels overconsolidates memory exhibited in intrusive flashbacks, thoughts, sensations, images.
  • Whether or not the same neural activity accounts for symptoms of DP in PTSD and in depersonalization disorder is unknown.
prefrontal cortex pathways in dpd
Prefrontal Cortex pathways in DPD
  • The prefrontal cortex plays a role in DPD.
  • The PFC inhibits or prevents sensory overload of stress by inhibiting the excitatory input from sensory association cortex to limbic structures. Excessive inhibtion by the PFC of the limbic system results in dissociation:
  • Patients say they cannot think. David, A. 2004
  • Interestingly, drug use can activate the prefrontal cortex, leading to inhibited activity in lower limbic sites, eliciting an episode of depersonalization.
major distinction between panic and dpt is breathing
Major distinction between panic and DPT is breathing
  • Panic and DPD as a subtype of panic differ with regard to the centrality of breathing distress.
  • The role of breathing distress is central to the experience of panic, although some researches emphasize the role of fear.
  • Klein proposes that persons vulnerable to panic suffer from a false suffocation alarm syndrome.
role of carbon dioxide
Role of carbon dioxide
  • Induced inhalation of carbon dioxide does elicit attacks in persons vulnerable to panic, and is more frequent in those with a family history of PD.
  • Hyperventilzation and/or breath holding have been found to trigger panic attacks.
  • The theories converge. Fear can elicit hyperventilation, or breath holding, initiating a cascade of events terminating in panic.


role of breathing
Role of breathing
  • The role of breathing dysfunction has not been specifically investigated in DPD
  • However clinical observation shows persons with DPD to be breath holders
  • And, most persons with DPD have a history of panic attacks, supporting the need to attend to dysfunctional breathing patterns in the disorder.
treatment implications
Treatment implications
  • From a treatment point of view the therapist is best prepared when there are techniques to address:
  • Maladaptive breathing patterns for panic or DPD
  • Specific symptoms of DPD (numbness, spectator reactions, sensory changes)
  • Anticipatory anxiety
about ecem
About ECEM
  • ECEM is a novel technique that utilizes self-generated eye movements by the client within a state of hypnosis.
  • Unlike EMDR, carried out in a conscious state of awareness, brief trials of EM's are incorporated within hypnosis at therapist suggestion.
  • EM's are preceded and followed by hypnotic processing.
advantages of ecem
Advantages of ECEM
  • ECEM, integrating hypnosis and EM's:
    • Utilizes core symptoms of DPD--spectator self, sensory, affective and cognitive numbing, derealization- -as naturally occurring hypnotic phenomena.
    • Uses suggestion to reverse and reframe these core symptoms to bring an episode of DPD under control.
treatment of dpd with ecem
Treatment of DPD with ECEM

ECEM (eye closure, eye movements within hypnosis) can be utilized to .

  • Reduce anticipatory anxiety of panic and episodes of DPD
  • Treat anxiety (cues) that trigger DPD
  • Provide a hypnotic context to stabilize and regulate dysfunctional breathing that indirectly trigger DPD

How to use ECEM to:

  • Manage breathing distress in:



  • Manage specific symptoms of DPD--sensory, cognitive and affective freezing, feeling like a spectator, feeling unreal
  • Manage anticipatory anxiety related to panic and DPD