Depersonalization/derealization disorder is a type of dissociative disorder that consists of persistent or recurrent feelings of being detached (dissociated) from one’s body or mental processes, usually with a feeling of being an outside observer of one’s life (depersonalization), or of being detached from one’s surroundings (derealization). The disorder is often triggered by severe stress. Diagnosis is based on symptoms after other possible causes are ruled out. Treatment consists of psychotherapy plus drug therapy for any comorbid depression and/or anxiety. About 50% of the general population has had at least one transient experience of depersonalization or derealization in their lifetime. However, only about 2% of people ever meet the criteria for having depersonalization/derealization disorder. Depersonalization or derealization can also occur as a symptom in many other mental disorders as well as in physical disorders such as seizure disorders (ictal or postictal). When depersonalization or derealization occurs independently of other mental or physical disorders, is persistent or recurrent, and impairs functioning, depersonalization/derealization disorder is present. Depersonalization/derealization disorder occurs equally in men and women. Mean age at onset is 16 yr. The disorder may begin during early or middle childhood; only 5% of cases start after age 25, and the disorder rarely begins after age 40.
People with depersonalization/derealization disorder often have experienced severe stress, such as the following:
- Being emotionally abused or neglected during childhood (a particularly common cause)
- Being physically abused
- Witnessing domestic violence
- Having a severely impaired or mentally ill parent
- Having a family member or close friend die unexpectedly
Episodes can be triggered by interpersonal, financial, or occupational stress; depression; anxiety; or use of illicit drugs, particularly marijuana, ketamine, or hallucinogens.
Symptoms and Signs
Symptoms of depersonalization/derealization disorder are usually episodic and wax and wane in intensity. Episodes may last for only hours or days or weeks, months, or sometimes years. But in some patients, symptoms are constantly present at an unchanging intensity for years or decades.
Depersonalization symptoms include
- Feeling detached from one’s body, mind, feelings, and/or sensations
Patients feel like an outside observer of their life. Many patients also say they feel unreal or like a robot or automaton (having no control over what they do or say). They may feel emotionally and physically numb or feel detached, with little emotion. Some patients cannot recognise or describe their emotions (alexithymia). They often feel disconnected from their memories and are unable to remember them clearly.
Derealization symptoms include
- Feeling detached from their surroundings (e.g., people, objects, everything), which seem unreal
Patients may feel as if they are in a dream or a fog or as if a glass wall or veil separates them from their surroundings. The world seems lifeless, colourless, or artificial. Subjective distortion of the world is common. For example, objects may appear blurry or unusually clear; they may seem flat or smaller or larger than they are. Sounds may seem louder or softer than they are; time may seem to be going too slow or too fast.
Symptoms are almost always distressing and, when severe, profoundly intolerable. Anxiety and depression are common. Some patients fear that they have irreversible brain damage or that they are going crazy. Others obsess about whether they really exist or repeatedly check to determine whether their perceptions are real. However, patients always retain the knowledge that their unreal experiences are not real but rather are just the way that they feel (i.e., they have intact reality testing). This awareness differentiates depersonalization/derealization disorder from a psychotic disorder, in which such insight is always lacking.
- Clinical criteria
Diagnosis of depersonalization/derealization disorder is clinical, based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):
- Patients have persistent or recurrent episodes of depersonalization, derealization, or both.
- Patients know that their unreal experiences are not real (i.e., they have an intact sense of reality).
- Symptoms cause significant distress or significantly impair social or occupational functioning.
Also, the symptoms cannot be better accounted for by another disorder (e.g., seizures, ongoing substance abuse, panic disorder, major depressive disorder, another dissociative disorder). MRI and EEG are done to rule out physical causes, particularly if symptoms or progression is atypical (e.g., if symptoms begin after age 40 year). Urine toxicology tests may also be indicated. Psychologic tests and special structured interviews and questionnaires are helpful.
Patients with depersonalization/derealization disorder often improve without intervention. Complete recovery is possible for many patients, especially if symptoms result from treatable or transient stresses or have not been protracted. In others, depersonalization and derealization become more chronic and refractory. Even persistent or recurrent depersonalization or derealization symptoms may cause only minimal impairment if patients can distract themselves from their subjective sense of self by keeping their mind busy and focusing on other thoughts or activities. Some patients become disabled by the chronic sense of estrangement, by the accompanying anxiety or depression, or both.
Treatment of depersonalization/derealization disorder must address all stresses associated with an onset of the disorder as well as earlier stresses (e.g., childhood abuse or neglect), which may have predisposed patients to late onset of depersonalization and/or derealization. Various psychotherapies (e.g., psychodynamic psychotherapy, cognitive-behavioural therapy) are successful for some patients:
- Cognitive techniques can help block obsessive thinking about the unreal state of being.
- Behavioural techniques can help patients engage in tasks that distract them from the depersonalization and derealization.
- Grounding techniques use the five senses (e.g., by playing loud music or placing a piece of ice in hand) to help patients feel more connected to themselves and the world and feel more real in the moment.
- Psychodynamic therapy helps patients deal with negative feelings, underlying conflicts, or experiences that make certain affects intolerable to the self and thus dissociated.
- Moment-to-moment tracking and labelling of affect and dissociation in therapy sessions work well for some patients.
Various drugs have been used, but none have demonstrable efficacy. However, some patients are helped by SSRIs, lamotrigine, opioid antagonists, anxiolytics, and stimulants. However, these drugs may work largely by targeting other mental disorders (e.g., anxiety, depression) that are often associated with or precipitated by depersonalization and derealization.
Credit: David Spiegel for MSD Manual, July 2017.