Abstract
Perminder Sachdev, Sydney, Australia:
While depersonalization as a symptom is not uncommon, primary depersonalization disorder is rare and remains poorly investigated [1]. There have only been a few reports of its psychopharmacological treatment, most of which are anecdotal, their major focus having been the selective seretonin re-uptake inhibitors (SSRIs) and benzodiazepines [1, 2]. This is understandable for a number of reasons: depersonalization as a symptom most commonly occurs in the setting of severe anxiety or depression; drugs that act on the serotonergic axis, such as hallucinogens and marijuana, induce depersonalization; and risk factors for depression and anxiety, such as childhood trauma, are also implicated in depersonalization. We report a patient who had a gradual but impressive improvement with a combination of citalopram and clonazepam after having failed trials with other medications.
A 24-year-old woman presented with symptoms of depersonalization and derealization for about 3 years, with fluctuations in severity. The onset was sudden and followed a period of prolonged stress. She had ceased using cannabis six weeks prior to onset. She described feeling ‘foggy’, as if ‘a veil has developed before my eyes’, not being able to ‘feel my own body’, being distant from other people and feeling ‘blunted’ in her emotions. There were periods of anxiety and depression that were not sustained beyond a few hours to days. Her symptoms persisted for about two years before she sought medical help. She had continued her studies as well as full-time work through this period. Premorbidly, she was highly strung and obsessional, with excessive concern about her weight and diet but no distortion of self-image. Her physical health was normal.
A DSM-IV diagnosis of Depersonalization Disorder was made, with mild depressive symptoms not meeting criteria for major depression. Initial treatment with paroxetine 20 mg/day over four weeks produced minimal change. A combination of cognitive–behaviour therapy and sertraline at 50 mg/day was used. She reported mild improvement in the ‘foggy feeling’ but discontinued the day after three months owing to drowsiness and tiredness. During this period, she used diazepam 5 mg on a few occasions without relief. She came across the citalopram-clonazepam combination on a Depersonalization discussion board on the Web, and expressed interest in this. She began with citalopram 10 mg/day, increasing it to 30 mg/day over four weeks, with mild improvement in symptoms. The introduction of clonazepam at 0.5 mg b.i.d. two weeks later resulted in a remarkable improvement. The doses were further increased to citalopram 40 mg/day and clonazepam 1.5 mg b.i.d. over the next month, with continuing improvement. After three months of treatment she was almost free of depersonalization except when under stress. She maintained improvement for 6 months when, secondary to severe interpersonal difficulties, she became depressed, resigned from her job and stopped medication. Symptoms returned at the previous level. With the reintroduction of the citalopramclonazepam combination, she showed gradual recovery, maintained for over a year. She resumed her employment, gained a promotion and considers herself to be almost symptom free. The dose of clonazepam was reduced to 3.5 mg/day and citalopram to 10 mg/day. Further reduction led to a mild recurrence.
It is not uncommon for patients to respond selectively to SSRIs. While it is uncertain whether this combination of citalopram and clonazepam is better than any other combination of an SSRI and a benzodiazepine, it is noteworthy that similar reports have been posted on the Web by a number of patients (http://www.depersonalization. hypermart.net/combo.net). Citalopram is highly selective for serotonin-reuptake inhibition [3], which may account for its good tolerability. Clonazepam is regarded among benzodiazepines to be an effective cotherapy with SSRIs in obsessive–compulsive disorder [4] and depression [5], and notable for use in mania and epilepsy. The action of clonazepam is worthy of further study as is the efficacy of the above combination.