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Depersonalization/Derealization Disorder

by David Spiegel, MD

Depersonalization/derealization disorder involves a persistent or recurring feeling of being detached from one’s body or mental processes, like an outside observer of their life (depersonalization), and/or a feeling of being detached from one's surroundings (derealization).

  • The disorder is usually triggered by severe stress, particularly emotional abuse or neglect during childhood, or other major stresses (such as experiencing or witnessing physical abuse).

  • Feelings of detachment from self or the surroundings may occur periodically or continuously.

  • After tests are done to rule out other possible causes, doctors diagnose the disorder based on symptoms.

  • Psychotherapy, especially cognitive-behavioral therapy, is often helpful.

Temporary feelings of depersonalization and/or derealization are common. About one fourth of people have felt detached from themselves (depersonalization) or from the surroundings (derealization) at one time or another. This feeling often occurs after people

  • Experience life-threatening danger

  • Take certain drugs (such as marijuana, hallucinogens, ketamine, or Ecstasy)

  • Become very tired

  • Are deprived of sleep or sensory stimulation (as may occur when they are in an intensive care unit)

Depersonalization or derealization can also occur as a symptom in many other mental disorders, as well as in physical disorders, such as seizure disorders.

Depersonalization/derealization feelings are considered a disorder when the following occur:

  • Depersonalization or derealization occurs on its own (that is, it is not caused by drugs or another mental disorder), and it persists or recurs.

  • The symptoms are very distressing to the person or make it difficult for the person to function at home or at work.

This disorder occurs in about 2% of the population and affects men and women equally.

The disorder may begin during early or middle childhood. It rarely begins after age 40.

Causes of Depersonalization/Derealization Disorder

Depersonalization/derealization disorder often develops in people who have experienced severe stress, including the following:

  • Being emotional abused or neglected during childhood

  • Being physically abused

  • Witnessing domestic violence

  • Having had a severely impaired or mentally ill parent

  • Having had a loved one die unexpectedly

Symptoms can be triggered by severe stress (for example, due to relationships, finances, or work), depression, anxiety, or use of illegal or recreational drugs.

Symptoms of Depersonalization/Derealization Disorder

Symptoms may start gradually or suddenly. Episodes may last for only hours or days or for weeks, months, or years. Episodes may involve depersonalization, derealization, or both.

The intensity of symptoms often waxes and wanes. But when the disorder is severe, symptoms may be present and remain at the same intensity for years or even decades.

Depersonalization symptoms involve feeling detached from one's body, mind, feelings, and/or sensations. People may also say they feel unreal or like an automaton, with no control over what they do or say. They may feel emotionally or physically numb. Such people may describe themselves as an outside observer of their own life or the “walking dead.”

Derealization symptoms involve feeling detached from the surroundings (people, objects, or everything), which seem unreal. People 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, colorless, or artificial. The world may appear distorted to them. For example, objects may appear blurry or unusually clear, or 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.

The symptoms almost always cause great discomfort. Some people find them intolerable. Anxiety and depression are common. Many people are afraid that the symptoms result from irreversible brain damage. Many worry about whether they really exist or repeatedly check to determine whether their perceptions are real.

Stress, worsening depression or anxiety, new or overstimulating surroundings, and lack of sleep can make symptoms worse.

Symptoms are often persistent. They may

  • Recur in episodes (in about one third of people)

  • Occur continuously (in about one third)

  • Become continuous (in about one third)

People often have great difficulty describing their symptoms and may fear or believe that they are going crazy. However, people always remain aware that their experiences of detachment are not real but rather are just the way that they feel. This awareness is what separates depersonalization disorder from a psychotic disorder. People with a psychotic disorder always lack such insight.

Diagnosis of Depersonalization/Derealization Disorder

  • A doctor's evaluation

  • Sometimes tests to rule out other possible causes

Doctors suspect the disorder based on symptoms. A physical examination and sometimes tests are done to rule out other disorders that could cause the symptoms, including other mental health disorders, seizure disorders, and substance abuse. Tests may include magnetic resonance imaging (MRI), computed tomography (CT), electroencephalography (EEG), and urine tests to check for drugs.

Psychologic tests and special structured interviews and questionnaires can also help doctors with the diagnosis.


Complete recovery is possible for many people, especially if the symptoms result from stresses that can be dealt with during treatment. Other people do not respond well to treatment, although they may gradually improve on their own. A few do not respond to any treatment.

Symptoms, even those that persist or recur, may cause only minor problems if people can keep their mind busy and focus on other thoughts or activities, rather than think about their sense of self. However, some people become disabled because they feel so disconnected from their self and their surroundings or because they also have anxiety or depression.

Treatment of Depersonalization/Derealization Disorder

  • Psychotherapy

  • Sometimes antianxiety drugs and antidepressants

Depersonalization/derealization disorder may disappear without treatment. People are treated only if the disorder persists, recurs, or causes distress.

Psychodynamic psychotherapy and cognitive-behavioral therapy have been effective for some people. Depersonalization/derealization disorder is often associated with or triggered by other mental health disorders (such as anxiety or depression), which require treatment. Any stresses that triggered the symptoms or that may have contributed to development of depersonalization/derealization disorder must also be addressed.

Techniques that can help include the following:

  • Cognitive techniques can help block obsessive thinking about the unreal state of being.

  • Behavioral techniques can help people become absorbed in tasks that distract them from the depersonalization.

  • Grounding techniques use the five senses (hearing, touch, smell, taste, and sight) to help people feel more connected to themselves and the world. For example, loud music is played or a piece of ice is put in the hand. These sensations are difficult to ignore, making people aware of themselves in the present moment.

  • Psychodynamic techniques focus on helping people work through intolerable conflicts, negative feelings, and experiences that people feel they must detach themselves from.

Antianxiety drugs and antidepressants sometimes help, particularly if people also have anxiety or depression.However, antianxiety drugs may also increase depersonalization or derealization, so doctors carefully monitor use of these drugs.

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