- Depersonalization is a persistent or recurrent experience of unreality, detachment, or being an outside observer of one’s own thoughts, feelings, and sensations, usually associated with altered perception, emotional or physical numbness, and distorted sense of time. This perception might also make the patient feel like they are observing their own body.
- Derealization is a persistent subjective sense of detachment or unreality of the surrounding world often described by the patient as unreal, dreamlike, foggy, lifeless, or visually distorted reality.
- Prevalence in the general population: approximately 2%
- Transient feelings of depersonalization or derealization occur much more frequently (approximately 19%).
- Depersonalization symptoms secondary to another pathology are more common.
- Prevalence is similar between sexes.
- Average age at onset: 16 years
- Risk factors:
- History of trauma
- History of substance abuse
- Anxiety or depressive disorders
- Thought to occur as a response to severe stressors
- Survival mechanism to manage stressful situations without feeling overwhelmed
- Organic causes:
- Seen in people with seizures and head injury (but the disorder is not directly caused by these)
- It is thought that there is a genetic predisposition to developing depersonalization/derealization disorder (DDD).
- Several neurotransmitter systems are thought to be involved (N-methyl-d-aspartate (NMDA), opioid, and serotonin) because administration of these causes a depersonalization experience.
- Brain regions like the parietal lobe and the right hemisphere are noted to have abnormal activity during a depersonalization experience.
- Hypoactivation of the limbic system, in particular the insula, has been also linked to depersonalization/derealization disorder.
- Conceptual models:
- Cognitive behavioral models: Fear is a central component, and the core components can be dissociation of affect (not feeling) and alexithymia (difficulty identifying and verbalizing emotions).
- Psychodynamic theories: an inability to integrate various aspects of one’s self-experience with the surrounding world
Diagnosis and Clinical Features
- Careful history taking, as well as neurologic exam, is essential for correct diagnosis.
- Diagnosis is clinical by meeting specific criteria:
- Presence of recurrent or persistent episodes of depersonalization, derealization, or both
- Reality testing remains intact during episodes.
- Episodes cause significant impairment in day-to-day function.
- Substance use (alcohol, lysergic acid diethylamide (LSD)), medical conditions (seizures, head injury), and other psychiatric conditions must be ruled out.
- To rule out organic causes, initial evaluation must include:
- Basic metabolic panel
- Urine toxicology screen
- Altered sense (misperception) of time: perceived as too fast or too slow
- Problems with memory consolidation and recall (memory impairment)
- Nonpathologic dissociation:
- Normal to experience dissociation during everyday daily activities
- Example: arriving at a destination in your vehicle without recalling the drive
- In nonpathologic dissociation, the patient does not experience feelings of distress or functional impairment.
Treatment must include psychoeducation as well as supportive psychotherapy.
- Main treatment option, especially for those without other psychiatric comorbidities
- CBT: Goal is to develop techniques to reframe dissociative symptoms as less threatening.
- Psychodynamic psychotherapy: Goal is to uncover intolerable emotions that may lead to the dissociative symptoms and create better ways to process them.
- Treat comorbid conditions (depression, anxiety).
- Lamotrigine (anticonvulsant) might be helpful as adjunct therapy to psychotherapy.
- Opioid-receptor antagonists (naltrexone) might help.
- Acute stress disorder: stress reactions displayed after an individual has experienced a traumatic event. Symptoms last > 3 days, but < 1 month and include reexperiencing the event as flashbacks or nightmares, avoidance of reminders of the event, irritability, hyperarousal, and poor memory and concentration. Those with DDD experience only the dissociative aspects and, therefore, do not qualify for the diagnosis of acute stress disorder.
- Hallucinogen use disorder: pathologic consumption of hallucinogenic substances that cause perceptual distortions (visual or auditory). Examples of substances ingested include psilocybin (mushrooms), LSD, and phencyclidine (PCP). These drugs are used for their psychedelic effects—a temporary altered state of consciousness. During acute intoxication, patients may experience depersonalization or derealization. Thorough history taking and toxicology screening can differentiate hallucinogen intoxication from DDD.
- Schizophrenia: chronic mental health disorder that is characterized by positive symptoms (delusions, hallucinations, and disorganized speech or behavior) and negative symptoms (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia is associated with a decline in functioning lasting > 6 months. Those with DDD may experience similar alterations in realities; however, reality testing remains intact, with no other positive/negative symptoms.
- Sadock BJ, Sadock VA, Ruiz P. (2014). Anxiety disorders. In Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. Philadelphia: Lippincott Williams and Wilkins, pp. 451–464.
- Aderibigbe YA, Bloch RM, Walker WR. (2001). Prevalence of depersonalization and derealization experiences in a rural population. Soc Psychiatry Psychiatr Epidemiol. https://pubmed.ncbi.nlm.nih.gov/11355447/
- Simeon D, Knutelska M, Nelson D, Guralnik O. (2003). Feeling unreal: a depersonalization disorder update of 117 cases. J Clin Psychiatry. https://pubmed.ncbi.nlm.nih.gov/14628973/
- Grigsby J, Kaye K. (1993). Incidence and correlates of depersonalization following head trauma. https://pubmed.ncbi.nlm.nih.gov/8260954/