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Depersonalization/Derealization Disorder

By

David Spiegel

, MD, Stanford University School of Medicine

Last full review/revision Mar 2021| Content last modified Mar 2021
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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 have 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 Seizure Disorders A seizure is an abnormal, unregulated electrical discharge that occurs within the brain’s cortical gray matter and transiently interrupts normal brain function. A seizure typically causes altered... read more (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 years. 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.

Etiology

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 Depressive Disorders Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more ; anxiety Overview of Anxiety Disorders Everyone periodically experiences fear and anxiety. Fear is an emotional, physical, and behavioral response to an immediately recognizable external threat (eg, an intruder, a car spinning on... read more ; or use of illicit drugs Overview of Substance-Related Disorders Substance-related disorders involve drugs that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific pleasurable... read more , particularly marijuana Marijuana (Cannabis) Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent... read more , ketamine Ketamine and Phencyclidine (PCP) Ketamine and phencyclidine are dissociative anesthetics that can cause intoxication, sometimes with confusion or a catatonic state. Overdose can cause coma and, rarely, death. Ketamine and phencyclidine... read more , or hallucinogens Hallucinogens Hallucinogens are a diverse group of drugs that can cause highly unpredictable, idiosyncratic reactions. Intoxication typically causes hallucinations, with altered perception, impaired judgment... read more .

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 for 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 recognize 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 (eg, 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, colorless, 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 (ie, they have intact reality testing). This awareness differentiates depersonalization/derealization disorder from a psychotic disorder, in which such insight is always lacking.

Diagnosis

  • Clinical criteria

Diagnosis of depersonalization/derealization disorder is clinical, based on the presence of the following 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 dissociative experiences are not real (ie, 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 medical or psychiatric disorder (eg, seizures, ongoing substance abuse, panic disorder, major depressive disorder, another dissociative disorder).

MRI and EEG are done to rule out structural causes, particularly if symptoms or progression is atypical (eg, if symptoms begin after age 40 years). Urine toxicology tests may also be indicated.

Psychological tests and special structured interviews and questionnaires are helpful.

Prognosis

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

  • Psychotherapy

Treatment of depersonalization/derealization disorder must address all stresses associated with onset of the disorder as well as earlier stresses (eg, childhood abuse or neglect), which may have predisposed patients to late onset of depersonalization and/or derealization.

Various psychotherapies (eg, psychodynamic psychotherapy, cognitive-behavioral therapy) are successful for some patients:

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

  • Behavioral techniques can help patients engage in tasks that distract them from the depersonalization and derealization.

  • Grounding techniques use the 5 senses (eg, by playing loud music or placing a piece of ice in the 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 labeling of affect and dissociation in therapy sessions works well for some patients.

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